San Dimas Retirement Center

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Allegation investigated: Facility is understaffed. Facility does not purchase diapers for residents. Facility has pests.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 08/13/2026 to deliver findings regarding the above allegations. LPA met with Erica Paredes, Med Tech and explained the purpose of the visit. The investigation included a review of the facility's resident roster, staff roster, staffing schedules and assignment sheets for all shifts, with emphasis on the PM and NOC shifts, as well as pest control invoices and treatment records related to reported pest activity. LPA conducted interviews with nine residents (R1–R9) and twelve staff members (S1–S12) during both daytime and NOC shift hours. LPA also contacted the facility's pest control provider, Orkin, to verify the frequency of pest control services. Additionally, LPA conducted facility tours and observations during both daytime and NOC shift hours to assess staffing levels, resident care and supervision, staff response to resident needs, the availability of incontinence supplies, and the overall cleanliness and sanitary condition of resident rooms, common areas, the kitchen, dining room, hallways, and storage areas for evidence of pest activity. (continued on 809C) Unsubstantiated Allegation: Facility is understaffed. It is alleged that the facility does not have sufficient staff to meet residents' care and supervision needs, particularly during the PM and night shifts, resulting in delays in resident care. During the investigation, LPA conducted interviews and facility visits during both daytime and NOC shift hours to assess staffing levels and resident care across different shifts. Staff provided varying information regarding staffing. Some staff stated that staffing is sufficient to meet residents' needs, while others reported that additional staff would be beneficial, particularly during the PM and NOC shifts. Staff stated that unexpected call-offs can result in residents waiting longer for assistance. Staff also reported that the facility utilizes registry staff when additional coverage is needed and is actively recruiting and hiring additional staff. During resident interviews, the majority of residents reported experiencing delays in care, particularly during the evening shift, and expressed that the facility appears to be short-staffed. Residents generally reported that staff eventually respond and provide the requested assistance; however, response times can be lengthy. LPA conducted observations during both daytime and NOC shift visits. During the NOC shift, LPA observed two caregivers assigned to Assisted Living and two caregivers assigned to Memory Care, with one medication technician monitoring the switchboard and resident call lights. LPA observed staff actively working and available to respond to resident needs. NOC staff interviewed reported that the shift is generally quiet, the workload is manageable, and the current staffing level is sufficient to meet residents' needs. Allegation: Facility does not purchase diapers for residents. It is alleged that the facility does not purchase diapers for residents, requiring family members to provide diapers while the facility primarily provides pull-ups. During interviews, staff stated that the facility manages residents' day-to-day incontinence supply needs based on each resident's individual circumstances. Some residents receive diapers automatically through their insurance, while some families choose to purchase diapers for their residents based on preference. Staff stated that when additional supplies are needed, the facility assists with obtaining diapers and maintains donated supplies for immediate use. During resident interviews, some residents stated that their families purchase their diapers, while others reported receiving diapers through their insurance and had boxes of supplies available in their rooms. Other residents stated that the facility assists them with obtaining diapers when needed. During the facility tour, LPA observed a supply room containing donated diapers in various sizes available for residents as needed. (continued on 809C) Allegation: Facility has pests. It is alleged that the facility has a roach infestation, with roaches observed in resident rooms, hallways, the cafeteria, elevator, and other areas of the facility. During staff interviews, multiple staff reported observing roaches in resident rooms, hallways, the elevator, and other areas of the facility. Maintenance staff acknowledged receiving complaints regarding roaches and stated that pest control services are conducted every Friday. During resident interviews, some residents reported observing roaches, while others stated they had not observed any.. During record review, LPA reviewed over six months of pest control treatment records from Orkin LPA also contacted Orkin and confirmed that weekly pest control services began in March 2026 and have continued as part of the facility's efforts to address and control pest activity. Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 28-AS-20260713192219

Allegation investigated: Staff are not ensuring a safe environment for resident. Staff are not ensuring resident is provided medication as prescribed. Staff are not ensuring that resident is attending appointments.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Karen Meacham and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of staff and residents, copies of R2’s behavioral contract, conducted a medication review, and completed interviews with 4 Staff (S1-S4) and 10 Residents (R1-R10). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not ensuring a safe environment for resident. It is alleged that R1’s significant other has displayed controlling and aggressive behavior toward R1 and staff does not prevent this from happening. LPA conducted interviews with 4 Staff, and each denied the allegation, staff stated that although R2 does have controlling behaviors, this is the spouse and next of kin for R1 and R1 has not stated they are fearful of R2. LPA reviewed R2’s Care Meeting Plan, Behavioral Contract and meeting notes that revealed R1 has been spoken to on 6/16/26, 6/24/26, 7/17/26 and 7/7/26 and R1’s verbally aggressive behaviors and interference with R1’s choices to attended activities were discussed and R1 agreed to discontinue this behavior. Per S1 and S3-S4, there was a meeting conducted 8/6/26 with R1, R2 and W1 where it was agreed that R2 will stop interfering with R1’s ADL’s, medication and doctors’ appointments and all parties agreed that R1 should move to the Memory Care wing at the facility but still be able to spend the day with R2, this move is scheduled for next week. LPA interviewed 10 Residents and each denied the allegation and stated that they feel safe at the facility. Allegation: Staff are not ensuring resident is provided medication as prescribed. It is alleged that R1’s significant other interferes with R1 receiving their medications. LPA conducted a medication review and all of R1's medication was accounted for and appear to be administered as prescribed. LPA interviewed 4 Staff and each denied the allegation, S1 and S3-S4 stated that R2 has interfered with medication being given to R1, that when it was time for medication they would encourage R1 to refuse the medication because they are still sleeping and haven’t eaten breakfast. Staff stated that the pharmacy and doctors were notified and they were able to change the medication time to a later time since R1 & R2 tend to sleep in late, the doctors changed the time for the medication as an attempt to have residents be more compliant with medication and this has been working. LPA interviewed 10 Residents and each denied the allegation and stated that they are always assisted with medications, medications are administered as prescribed, staff has never refused assisting with medication and staff re-fill their medications as needed. (Continued on LIC9099-C) Allegation: Staff are not ensuring that resident is attending appointments. It is alleged that R1’s significant other interferes with R1 attending scheduled appointments. LPA conducted interviews with 4 Staff, and each denied the allegation, staff stated that R2 was interfering with a doctor appointment for R1 as they did not want R1 in the van with the male driver, they were able to reschedule the appointment and also scheduled an appointment with the same doctor for R2, both residents went in transporting vehicle with driver, attended their appointments and moving forward this option will be made available so both residents can attend the appointments together. LPA interviewed 10 Residents and each denied the allegation and stated staff assist with both setting their doctor appointment and transportation to and from their appointment, residents also stated they are reminded of their upcoming appointments by staff. Based on statements and interviews conducted with Staff/Residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 28-AS-20260805181015

Allegation investigated: Staff leaves residents soiled for an extended period of time. Staff are double diapering residents. Staff turn residents' call button off during NOC shift. Staff does not provide a comfortable temperature for residents.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 07/23/2026 to deliver findings regarding the above allegations. LPA was greeted by Administrator Karen Meacham, and the purpose of the visit was explained. The investigation included a review of the facility's staff roster, resident roster, overnight staffing schedules, shift assignment sheets, maintenance records related to the Memory Care air conditioning system, maintenance work orders, and other documents relevant to the allegations. LPA conducted interviews with eight residents (R1–R8) and ten staff members (S1–S10). Additionally, LPA toured the facility, including the Memory Care unit, observed resident bedrooms and common areas, inspected the call light system, and assessed the temperature and operating condition of the Memory Care air conditioning system. Unsubstantiated Allegation:Staff leaves residents soiled for an extended period of time. It is alleged that staff leave residents soiled for extended periods of time. During staff interviews, staff consistently reported that facility policy requires residents requiring incontinent care to be checked, changed, and repositioned every two hours, or more frequently as needed. However, several staff members expressed concerns that this schedule was not consistently followed during the overnight (NOC) shift. Although some staff denied personally observing residents being left soiled, multiple staff members independently reported instances of delayed overnight incontinent care and residents being found soiled at the beginning of the day shift, raising concerns regarding the consistency of overnight care.During resident interviews, all eight residents (R1–R8) reported that staff assist them with their incontinent care needs. While several residents stated there are occasional delays in staff responding because caregivers are busy, they consistently reported that staff ultimately provide the necessary care and did not report being routinely left soiled for extended periods. Allegation: Staff are double diapering residents. It is alleged that staff are double-diapering residents. During staff interviews, staff consistently reported that facility policy prohibits double-diapering residents and stated residents requiring incontinent care are to be provided with appropriate briefs and timely changes. Several staff members acknowledged that double-diapering had occurred in the past or that residents have requested to wear two briefs. S7 stated some caregivers previously complied with resident requests to wear double briefs but reported nursing staff instructed caregivers that the practice is not permitted. S8 similarly stated double-diapering occurred when they first began working at the facility but reported it no longer occurs. S3 and S6 stated some residents have requested to be double-diapered; however, staff explain the practice is prohibited because it may contribute to skin irritation and skin breakdown. Several staff members also stated the facility conducted an in-service training for all caregivers emphasizing that double-diapering residents is not permitted. Staff reported they signed documentation acknowledging the training and understood that residents should receive timely incontinent care rather than being double-diapered. During the investigation, the facility provided LPA with a copy of the in-service training and staff sign-in sheet documenting that caregivers received training on the prohibition against double-diapering residents. During resident interviews, no residents reported being double-diapered or stated they had observed staff double-diapering other residents. Residents who required incontinent care reported staff provided assistance with toileting and changing as needed. (continued on 9099C) Allegation: Staff turn residents' call button off during NOC shift. Overall, the investigation identified conflicting information regarding the allegation. Several staff members reported concerns that the call light system had been turned off during the overnight shift, while other staff explained the system was only temporarily shut down to reset or repair mechanical malfunctions. Maintenance records confirmed the call light system experienced wiring issues that required repairs. Additionally, all eight residents interviewed (R1–R8) reported that staff generally responded when they activated their call lights, although several stated there were occasional delays because caregivers were assisting other residents. Staff does not provide a comfortable temperature for residents. It is alleged that staff do not provide a comfortable temperature for residents. During staff interviews, staff confirmed that the Memory Care air conditioning system experienced a temporary mechanical failure affecting three resident rooms. Staff consistently reported that the three affected residents were promptly relocated to rooms with functioning air conditioning while repairs were completed, and maintenance records verified that the necessary repairs were performed. Additionally, all eight residents interviewed (R1–R8) stated they had no complaints regarding the temperature within the facility or their rooms. During the investigation, LPA toured the Memory Care unit and visited each resident in their room, observing that the air conditioning was operational and the resident rooms maintained a comfortable temperature. Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 28-AS-20260722082723

Allegation investigated: Staff does not prevent resident from being harassed by another resident in care.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by staff and the purpose of the visit was explained. The investigation consisted of the following: LPA Gonzalez conducted an initial complaint visit, requested and obtained copies of Resident Roster, Staff Roster, interviewed staff 1- 6 (S1-S6) and interviewed residents 1- 8 (R1-R8). LPA reviewed files for R1 and R2 and obtained copies of Admission Agreement, physician’s report, ID/face sheet, care plan meeting notes and staff notes. continued on LIC 9099C Unsubstantiated Regarding allegation “Staff does not prevent resident from being harassed by another resident in care,” it was reported that R1 is tired of being harassed by R2 and R1 is tired of the racial slurs and inappropriate comments made by R2. LPA interviewed 6 staff. 6 out of 6 staff interviewed deny the allegation. S1 stated staff have spoken to R1 and R2 about the incident. R2’s family has been notified and R2 has been offered counseling. S1 stated staff conduct health and safety checks every 2 hours. S2 stated R1 and R2 have been separated by relocating to different rooms, down separate hallways. S2 stated they have spoken to R2 regarding boundaries and inappropriate language. S2 stated the police department was called, they spoke with R2 but did not leave a report. LPA interviewed 8 residents. 8 out 8 residents interviewed denied the allegation. R1 stated staff are handling the incident. R3 stated they reported an incident to staff and “staff were on it.” R3 stated staff addressed the incident and are taking care of the situation. R5 stated there was an issue but staff took care it, “It’s what they do. It’s their job and they do it.” R6 stated “staff are aware of the incident and they are handling it.” Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided tothe state’s words, verbatim · CDSS document, Jun 16, 2026 · control 28-AS-20260611164108

Allegation investigated: Questionable death.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit in response to the above-mentioned allegation. LPA met with Priscilla Gaytan, Administrator and explained the reason for the visit. The investigation consisted of the following: On 11/04/2025, LPA conducted a tour of the facility, including Memory Care. Assisted Living and common areas. LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports/SIRs (06/26/2025), Death report and pertinent facility files and Resident #1 (R1) files. LPA interviewed Staff #1 (S1) - Staff #2 (S2). LPA did not observe any immediate Health and/or Safety concerns. Prior to today's visit, LPA obtained pertinent files for R1, including death certidicate. On 05/04/2026, LPA obtained a copy of the Staff and Resident rosters, additional R1's files pertinent to the investigation. LPA telephonically reinterviewed Staff #1 (S1) - Staff #2 (S2) and interviewed Staff #5 (S5) - Staff #6 (S6). LPA also interviewed Staff #3 (S3), Resident #2 (R2) - Resident #11 (R11) in person. LPA made (3) attempts to interview Staff #4 (S4) but no response received. On 05/05/2026, LPA interviewed S4 on the phone. During today's visit, LPA obtained a copy of the Staff and Resident rosters and delivered findings. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: Questionable death. It is alleged that facility’s neglect caused R1’s death because they did not check R1’s vital signs (oxygen levels, blood pressure, or blood sugar) adequately. According to information obtained, R1 was admitted to the facility on 05/04/2022, did not have a 1:1 care, was alert, and had been diagnosed with Dementia. After being examined by a doctor, R1 was moved from Memory Care to Assisted Living on 01/30/2024. On 06/25/2025, at approximately 6:30am, S4 assessed R1 due to a complaint of abdominal pain and constipation and then called the doctor for evaluation. At approximately 8:30am, S4 spoke with FM (R1’s responsible party) to give an update on R1’s condition and to ask if they would want to bring R1 to the hospital for further evaluation, but FM decided to do in-house treatment for R1 instead. Afterwards, S4 called the doctor over again who then gave R1 a prescription for a laxative and suppository. All staff interviewed stated that R1 was placed on 1–2-hour checks. Staff stated they provided proper care to R1 by assessing pain, bowel movements, abdominal distension, palpation, vital signs monitoring and reporting to the physician, as well as kept an eye out for any changes in condition. When assessed, four (4) on-duty staff interviewed stated that R1 was alert, vital signs were stable and did not exhibit signs of distress. Staff decided to take R1 to the hospital after R1 had refused to take the prescribed medication, and the suppository failed to work. R1 refused to be taken to the hospital and signed the Refusal of Medical Attention form at 5:25pm. Staff contacted FM to get permission for the hospital transfer. At approximately 8:00pm, S6 contacted the non-emergency transportation service to take R1 to the hospital. FM was also contacted by S6 to report on R1's situation and condition. At 11:50pm, R1 was taken to the hospital by the non-emergency transportation service, and R1 passed away two (2) days later, on 06/27/2025. Staff interviews, medication records and chart notes revealed that they implemented appropriate interventions, checked vital signs frequently throughout the day, administered prescribed laxatives and monitored R1's symptoms. Based on record reviews, reports and interviews gathered, the findings indicate that R1 had pre-existing health conditions and there was no physician’s order to monitor R1’s vital signs at regular intervals throughout the day or week. LPA obtained a copy of the Death Certificate that stated the immediate cause of death was Cardiopulmonary Arrest. The death has no indication of neglect, or lack of care and supervision. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Priscilla Gaytan, Administrator.the state’s words, verbatim · CDSS document, May 8, 2026 · control 28-AS-20251031163810

Allegation investigated: Questionable death.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit in response to the above-mentioned allegation. LPA met with Priscilla Gaytan, Administrator and explained the reason for the visit. The investigation consisted of the following: On 11/04/2025, LPA conducted a tour of the facility, including Memory Care. Assisted Living and common areas. LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports/SIRs (06/26/2025), Death report and pertinent facility files and Resident #1 (R1) files. LPA interviewed Staff #1 (S1) - Staff #2 (S2). LPA did not observe any immediate Health and/or Safety concerns. Prior to today's visit, LPA obtained pertinent files for R1, including death certidicate. On 05/04/2026, LPA obtained a copy of the Staff and Resident rosters, additional R1's files pertinent to the investigation. LPA telephonically reinterviewed Staff #1 (S1) - Staff #2 (S2) and interviewed Staff #5 (S5) - Staff #6 (S6). LPA also interviewed Staff #3 (S3), Resident #2 (R2) - Resident #11 (R11) in person. LPA made (3) attempts to interview Staff #4 (S4) but no response received. On 05/05/2026, LPA interviewed S4 on the phone. During today's visit, LPA obtained a copy of the Staff and Resident rosters and delivered findings. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: Questionable death. It is alleged that facility’s neglect caused R1’s death because they did not check R1’s vital signs (oxygen levels, blood pressure, or blood sugar) adequately. According to information obtained, R1 was admitted to the facility on 05/04/2022, did not have a 1:1 care, was alert, and had been diagnosed with Dementia. After being examined by a doctor, R1 was moved from Memory Care to Assisted Living on 01/30/2024. On 06/25/2025, at approximately 6:30am, S4 assessed R1 due to a complaint of abdominal pain and constipation and then called the doctor for evaluation. At approximately 8:30am, S4 spoke with FM (R1’s responsible party) to give an update on R1’s condition and to ask if they would want to bring R1 to the hospital for further evaluation, but FM decided to do in-house treatment for R1 instead. Afterwards, S4 called the doctor over again who then gave R1 a prescription for a laxative and suppository. All staff interviewed stated that R1 was placed on 1–2-hour checks. Staff stated they provided proper care to R1 by assessing pain, bowel movements, abdominal distension, palpation, vital signs monitoring and reporting to the physician, as well as kept an eye out for any changes in condition. When assessed, four (4) on-duty staff interviewed stated that R1 was alert, vital signs were stable and did not exhibit signs of distress. Staff decided to take R1 to the hospital after R1 had refused to take the prescribed medication, and the suppository failed to work. R1 refused to be taken to the hospital and signed the Refusal of Medical Attention form at 5:25pm. Staff contacted FM to get permission for the hospital transfer. At approximately 8:00pm, S6 contacted the non-emergency transportation service to take R1 to the hospital. FM was also contacted by S6 to report on R1's situation and condition. At 11:50pm, R1 was taken to the hospital by the non-emergency transportation service, and R1 passed away two (2) days later, on 06/27/2025. Staff interviews, medication records and chart notes revealed that they implemented appropriate interventions, checked vital signs frequently throughout the day, administered prescribed laxatives and monitored R1's symptoms. Based on record reviews, reports and interviews gathered, the findings indicate that R1 had pre-existing health conditions and there was no physician’s order to monitor R1’s vital signs at regular intervals throughout the day or week. LPA obtained a copy of the Death Certificate that stated the immediate cause of death was Cardiopulmonary Arrest. The death has no indication of neglect, or lack of care and supervision. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Priscilla Gaytan, Administrator.the state’s words, verbatim · CDSS document, May 8, 2026 · control 28-AS-20251031163810

Allegation investigated: Staff do not provide a safe environment for residents.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by staff and the purpose of the visit was explained. The investigation consisted of the following: On 04/28/2026, LPA Gonzalez conducted an initial complaint visit, requested and obtained copies of Resident Roster, Staff Roster, interviewed staff 1- 8 (S1-S8) and interviewed residents 1- 11 (R1-R11). LPA reviewed files for R1 and R2 and obtained copies of Admission Agreement, physician’s report, ID/face sheet and staff notes. During today’s visit LPA delivered findings. continued on LIC 9099C Unsubstantiated Regarding allegation “Staff do not provide a safe environment for residents,” it was reported that a resident received numerous explicit, graphic and harassing voicemail messages from another resident and when reported to staff, no action was taken. R1 stated they had not given R2 their phone number and was not able to confirm how R2 had gotten R1’s phone number. R1 stated the calls were received by a private number. S1 and S2 stated R1 was provided emotional support and S2 offered to call the Sheriff. The Sheriff indicated that there was no evidence to prove that it was R2. The Sheriff stated they would have a conversation with R2 asking them not to call R1. R2 denied calling R1. S2 heard the voicemails but was unable to identify the caller’s voice to be R2’s. S3, S4, S5 and S7 indicated when residents complain about having conflicts with other residents, staff try to resolve the issue by talking to the residents and come to a common understanding between the residents and report the issue to supervisors. Staff also indicated complaints have been minor and did not involve law enforcement. 10 out of 11 residents interviewed indicated they feel safe at the facility. R3 stated they feel very safe. R4 stated they feel safe and just avoid obnoxious people. R3, R5, R7, R9, and R10 stated they have not had any problems with other residents and have not had to report any conflicts with other residents to staff. R11 stated they had a situation with R2 but R11 asked R2 to leave them alone. R11 stated R2 has done what was asked by R11 and R11 has not had any problems with R2. R11 did not feel the need to report the situation to staff. R11 stated they feel safe at the facility. Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 1, 2026 · control 28-AS-20260420155443

Allegation investigated: Staff did not assist resident with dentist needs Facility is unsanitary Staff is unresponsive to resident's family inquiry Staff did not ensure refrigerator in resident's room was maintained in operable condition

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA Gonzalez was greeted by staff and the purpose of the visit was explained. Wellness Director Anne Graves assisted LPA with the tour. The investigation consisted of the following: On 02/24/2026, LPA Gonzalez conducted an initial complaint visit, requested and obtained copies of Resident Roster, Staff Roster, maintenance logs, and pest control service logs. LPA toured the facility physical plant, inspected residents’ rooms, reviewed file for R1, interviewed staff 1- 5 (S1-S5) and interviewed residents 1- 5 (R1-R5). During today’s visit LPA interviewed staff 6-7 (S6-S7), residents 6-9 (R6-R9) and inspected four (4) additional resident rooms. continued on LIC 9099C Unsubstantiated The investigation revealed the following: Regarding allegation “Staff did not assist resident with dentist needs,” it was reported that facility staff have not assisted R1 with seeing a dentist to replace their missing dentures, R1 was missing top and bottom dentures and dental follow up has been repeatedly delayed. Interview with R1 revealed R1 stated they have attended dental appointments and have received new dentures. R1 was not able to confirm if they had missed any dental appointments. LPA reviewed documents for dental appointments scheduled for R1 for 08/22/25 impressions for dentures, 10/10/25 bite registration for dentures, 10/22/25 (rescheduled to 10/28/25) try on dentures, 01/27/26 pick up dentures and 02/16/26 adjustment to dentures. 6 out of 9 residents interviewed stated staff help make appointments and arrange transportation for appointments. 2 out of 9 residents stated they make their own appointments or family make appointments for them. Regarding allegation “Facility is unsanitary,” it was reported that staff have not treated R1’s room for bugs even though the resident and the family have made multiple requests and staff did not address the unsanitary refrigerator in R1’s room that had an odor when opened. Interview with R1 revealed R1 stated they notified maintenance of a bug on the wall and maintenance “came and sprayed.” LPA reviewed maintenance log dated 02/08/26 indicating R1’s room was treated for bugs in room. LPA reviewed invoices for biweekly pest control services. Invoice dated 02/10/26 indicated R1’s room had been serviced for pest control, “no pest activity found inside the room.” 6 out of 9 residents interviewed stated they had not seen bugs in their rooms. R1 stated their refrigerator was working. LPA opened R1’s refrigerator and observed it to be clean and odorless at the time of visit. 9 out of 9 residents interviewed stated housekeeping cleans their room everyday and deep clean their room once a week which includes cleaning the refrigerator. continued on LIC 9099C page 3 Regarding allegation “Staff is unresponsive to resident family's inquiry,” it was reported that staff is unresponsive to family’s request. Interviews with staff revealed that due to confidentiality, staff will only report resident information to residents and their responsible party on file. LPA interview with staff and review of R1’s facility file revealed staff are in contact with R1’s responsible party on record. 8 out of 9 residents interviewed stated that they have not had any issues with staff reporting to the residents or their responsible party. Regarding allegation “Staff did not ensure refrigerator in resident's room was maintained in operable condition,” it was reported that staff have not fixed the refrigerator that came with R1’s room that stopped working. Interview with R1 revealed R1 stated their refrigerator is working. LPA inspected R1’s refrigerator and observed it to be operable at the time of visit. Interviews with staff revealed they did not have any work orders to repair or replace a refrigerator for R1. LPA reviewed maintenance logs and did not see any request for repair or replacement of a refrigerator for R1. 8 out of 9 residents interviewed indicated their facility-provided refrigerator is functional and have not had any problems. Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Wellness Director Anne Graves.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 28-AS-20260217085938

Allegation investigated: Due to lack of supervision, resident touched another resident inappropriately.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Anne Graves. The purpose of the visit was explained. The investigation consisted of the following: On 6/19/25, LPA S. Vaid conducted the initial visit and obtained the following documents: residents’ ID and emergency information, physicians' medical report, medications list, admissions agreement, and house rules. During the visit today, LPA Chan interviewed seven (7) staff and eleven (11) residents. Administrator K. Meacham was interviewed via telephone. Unsubstantiated The investigation revealed the following: Allegation - Due to lack of supervision, resident touched another resident inappropriately. It is alleged that Resident #1 (R1) was touched by Resident #2 (R2), who grabbed R1 by the breast, kissed, and forced the tongue down R1’s throat. LPA obtained and reviewed both residents’ files. The facility had completed an incident report for this alleged incident and sent it to licensing. It was noted that R1 reported that R2 had grabbed the breast and tried to kiss the resident by forcing the tongue into the mouth. R1 stated there were no witnesses, did not recall the date and time, and did not want to call the police. R2 was interviewed by the administrator who denied touching or kissing R1. LPA interviewed the administrator and seven (7) staff. The administrator stated that R1 had reported the incident and followed up on the case in which there was no evidence to support it. Staff stated that they are always supervising the residents to ensure their safety. Staff have never seen R2 behaving inappropriately at the facility. Staff have not seen R1 and R2 communicating with each other, having any type of relationship, or going to each other’s rooms. Staff are aware that R1 is a smoker and have heard that R1 likes to ask for cigarettes from other smokers. LPA interviewed Residents #1 - #11. The alleged perpetrator denied kissing or touching R1. R1 stated the incident occurred in R2’s room and nobody witnessed it. Other residents interviewed have not observed any residents inappropriately touching or kissing anyone. Residents feel safe at the facility and most state that staff monitor residents throughout the day and will intervene when necessary. Based on the information gathered, there were no witnesses who observed this incident, and no reports of R2 engaging in this type of behavior in the past, which requires an increase of supervision. LPA did not find sufficient evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Anne Graves. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 28-AS-20250613081850

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Priscilla Gayton, Administrator, the purpose of the visit was explained. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money. (continued on 809C) (continued from 809) Physical Plant/Environment Safety: The facility is a two-story building, approved to care for 343 non-ambulatory elderly residents, ages 60 and over. The facility has a memory care unit for dementia residents and has a hospice waiver approved for (30). LPA inspected random resident bedrooms and observed them to have the required furniture, bedding, linens,, closet space, and additional storage space. Each resident bedroom is equipped with a bathroom that consists of a shower, toilet, and wash basin One resident had two light bulbs out and they were replaced during visit. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. Several fire extinguishers were observed throughout the facility. Water temperature measure between 106.0 – 113.7 which is within range of 105.0 -120.0 degrees F: in random rooms that were inspected. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped, and facility is clean and free of odors. Fire department inspected the sprinkler system on 02/26/2025 and passed. Smoke detectors were tested and operational in random rooms checked. A shaded area with chairs is provided. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. Staffing: There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 6 staff files with no issues observed. Administrator Priscilla Gayton certificate expires on 03/04/2026 (continued on 809C) (continued from 809C) Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed. All medications are administered as order by the physician. Medical and dental transportation is provided by family, transportation services, or staff. Resident records/incident reports Resident files included appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway. One resident did not have ambulation status on LIC610 Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. No deficiencies observed during the visit. Technical Violations issued. Exit interview was conducted with Anne Graves, LVN Supervisor. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 9, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure resident was allowed to be readmitted to facility

*** this report supersedes report dated 6/17/25 reason is to include additional information. There are no changes to the findings, which remain unsubstantiated *** Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent visit to investigate the above allegations. LPA met with Karen Meacham and discussed the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff/resident rosters, copies of R1's Discharge Summary dated 7/15/25 and R1's facesheet, LPA interviewed 4 staff (S1-S4) and 11 residents (R2-R12). R1 was not able to be interviewed as they are no longer a resident at the facility, LPA was able to interview R1's responsible party during visit via telephone call. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident was allowed to be readmitted to facility. It is alleged that staff are refusing to readmit R1 after hospitalization, claiming that they cannot provide care for R1. LPA interviewed 4 staff and each denied the above allegation. Interviews with S1 and S4 revealed that R1 was having a lot of difficulties at the facility, including being verbally aggressive towards staff and other residents and throwing objects in their room. S1 and S4 also stated that R1’s condition had progressed into treatment that facility could not provide and R1 needed a higher level of care, staff also stated that R1’s son was very involved in the relocation of R1 and was the induvial (along with R1) who decided to discharge R1 from facility. LPA soke with R1’s responsible party via telephone and they stated that R1 was in need of a higher level of care and this was understood and agreed with the facility staff and family, and that R1 was not refused readmittance it was due to a change of condition and a need of increased care. LPA interviewed 11 residents and each denied the alliteration, 8 of the 11 residents stated that they have been hospitalized and never had any issues returning to the facility post hospitalization. Based on statements and interviews conducted with staff/residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was emailed.the state’s words, verbatim · CDSS document, Oct 6, 2025 · control 28-AS-20250613111812

Allegation investigated: Staff did not provide resident transportation to medical appointments Staff tampered with residents’ mail Staff were harassing resident

*** this report supersedes report dated 6/17/25 reason is to include additional information. There are no changes to the findings, which remain unsubstantiated *** Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent visit to investigate the above allegations. LPA met with Karen Meacham and discussed the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff/resident rosters, toured facilities mail area and inspected mail, reviewed facilites transportation log and obtained copies of the log from May-October 2025, interviewed 4 Staff (S1-S4) and 11 residents (R2-R12), R1 was not able to interviewed as they are no longer a resident at the facility and LPA was not able to reach R1 through several phone call attempts. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide resident transportation to medical appointments It is alleged that R1 has missed doctors’ appointments due to facility not providing transportation. LPA interviewed 4 staff and each denied the above allegation. Interview with S2 revealed that residents prefer using the facility van, however, if they do not schedule their transportation in a timely manner there may be situations where the slots are full. S2 stated if the slots for transportation are full, the residents are also offered other sources of transportation such as access/dial a ride/uber. LPA interviewed 11 residents and each resident denied the above allegation and stated they haven’t had any issues with getting transportation, interviews revealed that although sometimes the appointments for rides with the facility van are booked they are offered other sources of transportation or use the transportation service provided through their insurance. Allegation: Staff tampered with residents’ mail It is alleged that R1’s mail had been opened with envelopes taped together, and S2 stated the mail was opened by accident. LPA toured mail area, observed mail in mail boxes and did not see any mail that appeared to be tampered with or opened, each envelope appeared well sealed and unopened. LPA interviewed 4 staff and each denied the above allegation, interviews revealed that the receptionist is who sorts through the mail and will sort the mail by placing the residents number on it and then distributing the mail in proper slots, staff each stated they have never tampered with the mail or observed a staff doing this. LPA interviewed 11 residents and each resident denied the allegation and stated they have never observed their mail to look tampered with. Allegation: Staff were harassing resident It is alleged that S2 and S5 are making false accusations towards R1 which is causing R1 distress. LPA interviewed 4 staff and each staff denied the above allegation, interviews with S1, S2 and S4 revealed that R1’s room once had the fire sprinkler go off and through investigation questions such as: were you smoking? Did something burn?, were being asked and they believe this is where R1 felt accused but these were just questions that need to be asked for the investigation not to accuse R1 or to make them feel harassed. LPA interviewed 11 residents, and each denied the allegation and stated staff have never made them feel harassed or accused of things. Based on statements and interviews conducted with staff/residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was emailed.the state’s words, verbatim · CDSS document, Oct 6, 2025 · control 28-AS-20250220160903

Allegation investigated: Staff stole resident’s money and personal belongings.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with Staff, Esmeralda Lerma. The purpose of the visit was explained. LPA obtained copies of the staff and resident rosters and reviewed documents. Interviews were conducted with Staff #1 - #6, and Residents #1 - #10. Allegation - Staff stole resident’s money and personal belongings. It is reported that on 8/2/25, staff stole $1,000 from Resident #1’s key safe and other personal items such as perfume, Phone cord, and K-cups. According to staff interviews, they were not aware that Resident #1 (R1) was keeping money at the facility. Unsubstantiated Staff stated R1 does not require staff assistance and only obtains housekeeping service. Staff indicated that R1 declined to have caregivers check on R1 in the evening during their 2-hour rounds. R1’s personal property and valuable form list does not include the alleged stolen personal items or cash entrusted to the facility to safeguard. A police report was filed for this alleged incident on 8/2/25. LPA interviewed ten (10) residents today. Three (3) out of ten (10) residents stated they have missing or stolen items from their rooms. Two of the three residents who had missing items believed that staff stole their cash and belongings. The resident, who stated cash was stolen, kept it in a safe and did not disclose to staff that money is being kept at the facility until the alleged incident. Residents stated they have a key to their room, and many will lock the door when they leave. During the visit today, LPA reviewed the surveillance footage for dates 8/1/25 – 8/2/25. Footage showed that caregivers, a housekeeper, and a resident had visited R1’s room. However, there was no evidence to show that a person entered the room when R1 was not present. Based on the information gathered, there is no supporting evidence to state that staff stole the resident’s money and personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Anne Graves. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 28-AS-20250818151203

Allegation investigated: . Unlawful Eviction. 2. Facility did not prevent resident from being harassed by other residents. 3. Facility failed to maintain resident's citizenship documents. 4. Staff does not respond to resident’s call button in a timely manner. 5. Facility is opening residents' mail before providing it to them. 6. Facility is not providing adequate food service. 7. Facility is failing to coordinate and provide transportation for residents to their medical appointments.

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a complaint investigation on the allegations listed above. LPAs arrived unannounced and met with the Co-Administrator, Karen Meacham. The purpose of the visit was explained. The investigation consisted of the following: LPAs obtained a copy of the staff and resident rosters. LPA toured the facility and interviewed the Administrators, five (5) Staff, and ten (10) Residents. Resident #1 (R1) is no longer residing at the facility, and attempt to interview R1 was made. The investigation revealed the following: Allegation – unlawful eviction. It is alleged that Resident #1 (R1) was issued an eviction letter for reasons that were untrue. LPA interviewed the administrators and staff. Unsubstantiated Administrators indicated the reasons listed on the eviction letter were true and have witnesses to confirm the dates of occurrences. Per the administrators, they have tried working with R1 and had a behavioral contract in place. However, R1’s conduct has not improved and has escalated in severity. Some staff interviewed have observed R1 being verbally aggressive and harassing others. LPA obtained and reviewed the 30-day eviction letter that was issued to R1 on 6/23/25. The eviction letter included the specific facts for the cause of eviction. The residents interviewed today have not received any eviction notices. Allegation - Facility did not prevent resident from being harassed by other residents. It is alleged that the administrators are not preventing R1 from being harassed by the 4 female residents. Administrators were not aware of R1 being harassed by other residents until recent. Administrators stated that staff will intervene immediately if they observe any inappropriate behaviors or altercations. Administrators will address any issues between residents individually and will not disclose to other residents what is being done. Staff interviewed stated that they are always monitoring residents and ensuring their safety. Staff will try to de-escalate any situations amongst residents when they need to and ask residents to stop the inappropriate talks. Ten out of ten residents stated that they have seen staff intervene right away if there are any issues among residents. Allegation - Facility failed to maintain resident's citizenship documents. It is alleged that the administrator was safeguarding R1’s citizenship document, and when asked, the administrator either lost or misplaced it. LPA interviewed the administrators, who both stated they did not recall R1 asking them to safeguard any documents. Both stated that R1 had requested it right before moving out; however, administrators informed R1 that they did not keep any documents of such in their office and that they do not have a safe as alleged. Administrators stated that they would have documented it on their safeguarding/valuable form if they kept it. Ten out of ten residents have not asked the administrators to keep anything for them. Residents stated they stored their belongings and valuables in their rooms. Allegation - Staff does not respond to the resident’s call button in a timely manner. It is alleged that staff did not respond to a fall for up to 2 hours due to staff not available. Administrators stated that every room is equipped with pull cords by their bedside and in the bathrooms. When a resident pulls the cord, it alerts the front desk, and the receptionist will respond to the call. The receptionist will call for a staff to assist the resident right away. Caregivers have walkie-talkies that they carry throughout their shifts. Staff interviewed stated they respond to calls right away and do room checks at least every 2 hours. LPA interviewed ten residents, and all the residents stated that the staff assist them right away when they call for them. Allegation - Facility is opening residents' mail before providing it to them. Administrators and staff interviewed have not opened any of the residents’ mail. Staff stated that residents’ mail is placed in their mailboxes. The residents who reside in the Garden area get their mail from the front desk. Ten out of ten residents have not received opened mail. Allegation - Facility is not providing adequate food service. It is alleged that staff is preventing residents from getting second helpings of food, no extra desserts, and causing residents to go hungry. Administrators and staff interviewed denied this allegation and stated that residents are given extra servings if they want. Staff stated that when residents want extra of something, they would inform the kitchen staff to get it for them. The menu lists the food items for the day. In addition, the facility has an alternative menu that residents can select from. Ten out of ten residents stated they are given additional servings if they want. However, many stated the portion amount is sufficient and do not request more. Allegation - Facility is failing to coordinate and provide transportation for residents to their medical appointments. LPA interviewed the administrators and staff, who stated there is a Social Services Aide who assists residents with making their medical appointments and arranging transportation. Staff have not heard of residents’ medical appointments being cancelled last minute or that residents were not informed of their appointments. Residents who have upcoming appointments are given a slip indicating the appointment time and date. The staff will speak to residents directly a week before to remind them of the appointments and provide them with a slip, which states the transportation pick up date and time and the doctor’s contact information. Seven out of ten residents stated the facility assists with coordinating and transporting them to their medical appointments. Two of the residents arrange their own medical appointments and transportation, while one did not respond to this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator, K. Meacham. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 28-AS-20250715133005

Allegation investigated: Staff did not seek timely medical care for resident. Staff did not ensure resident’s medical equipment was maintained in operable condition.

Licensing Program Analyst (LPA, Mayra Cota, conducted a 10-day complaint visit to the facility Licensing Program Analyst (LPA) Mayra Cota visited the facility to conduct the 10-day complaint investigation regarding the allegations listed above. Upon arrival, LPA met with Esmeralda Lerma Ramirez, Administrative Assistant, and the reason for the visit was explained. Anne Graves, LVN Supervisor, assisted LPA with the visit due to administrative staff being off. The investigation consisted of the following: At the time of visit, LPA Cota, obtained copies of staff and resident rosters, conducted a tour of the common areas of the facility, reviewed SIRs and Resident 1 file, and obtained copies of all relevant documents for the investigation. LPA Cota, also conducted interviews with Staff 1-Staff 5 (S1-S5) and Resident 1-Resident 8 (R1-R8). ****Continues on LIC 9909-C Unsubstantiated Regarding: Staff do not seek timely medical care for resident. It is alleged facility staff did not seek medical attention in a timely manner for R1 on 7/16/25 when they were having trouble breathing and they asked staff to call 911 because they were turning blue. It is also alleged that 911 was finally called after 15 minutes in which they were eventually transported to the ER by ambulance. Furthermore, the allegation also states, staff have not helped resident look into getting a follow up on results for blood work taken seven months ago. The investigation revealed the following: Interviews with staff (1),(2) and (3) revealed, staff called 911 within (2) to (5) minutes of getting the call button alert from R1 in which R1 requested 911 to be called thorough the speaker. Three (3) staff stated, as soon as front desk staff (S4) called staff to answer to the 911 request from R1, (3) staff made their way to R1's room to check and provide assistance. S1 and S2 stated, R1 refused to get his vital signs checked, which is standard protocol when a resident is requesting emergency medical services; however, staff continued to attempt to get their vitals as 911 was being called. S1, S2 and S3 stated, ambulance arrived in less than (10) minutes and R1 was transported to the hospital. S4 stated, upon receiving the call button alert from R1 to the front desk, they immediately informed S3 to check in on R1 and S1 and S2 rushed to R1's room to assist. Seven (7) out of (8) resident interviews indicated, staff help with emergency medical calls in a timely manner. Seven (7) out of (8) residents also stated, they have no concerns with staff not providing care in a timely manner. Interview with R1 indicated, staff took too long to call 911 when they were having trouble breathing. Regarding staff not helping resident look into getting a follow up on results from blood work taken seven months ago, interviews with S1, S2 and S5 indicated, R1's referral to see specialist has been approved and now has an appointment which S2 helped resident in obtaining. Staff stated, R1 makes his own appointments; however, staff have offered to help him with scheduling appointments but R1 refuses. Interviews with (7) out of (8) residents indicate, staff are helpful with making their appointments for them if needed. Furthermore, (7) residents stated, staff are good at reminding residents about upcoming appointments Interview with R1 indicated, staff did not help with getting his blood work results; however, R1 now has an appointment to see the specialist. Staff and resident interviews do not corroborate the allegation. ***Continies on LIC 9099-C Regarding: Staff did not ensure resident’s medical equipment was maintained in operable condition. It is alleged that R1 had been asking staff to replace their breathing equipment which was damaged in a flood in their room and nothing had been done about it. The investigation revealed the following: Interviews with S1, S2, S3 an S5 indicated, R1 was provided with a loaner breathing machine immediately after the incident in which R1's breathing machine broke down. Interviews with (4) staff indicated, R1 manages their own breathing treatment medication by ordering it, picking it up from their pharmacy of preference and administrating the medication themselves. Four (4) staff stated, they will offer R1 to place orders for their medication if needed; however, R1 refuses to accept staff's help and manages their own breathing treatment and ordering their medication and supplies. R1's interview indicated, they were using the loaner breathing machine provided by facility staff after theirs broke down; however, R1 stated, staff should have helped them order a new one to replace the broken one. R1 stated, they don't like to go through staff when ordering their breathing treatment medication and supplies because facility pharmacy may take too long. Record review indicated, R1 is able to perform their own inhaler and nebulizer treatments, which also includes picking up their own prescription and supplies from their preferred pharmacy. Interviews with (7) out of (8) residents indicated, staff have not been neglectful to their medication and/or supply needs. Seven (7) residents stated, staff help with ordering medication and/or medication supplies in a timely manner when needed. Staff and resident interviews and record review, do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 28-AS-20250717095142

Allegation investigated: Facility staff are not preventing a resident from harassing other residents

On 07/14/2025, Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit to re-deliver findings regarding the above allegation. The findings will remain the same. On 05/29/25, LPA Ramirez conducted an unannounced initial complaint investigation visit regarding the above allegation. During today’s visit, LPA Ramirez was greeted by Administrator Priscilla Gaytan explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 3 interviews (S1 – S3), Resident#1-7 Interviews (R1-R7), Copies of resident#4 (R4) recent physician’s report, admission agreement, special incident reports, and physical plant tour. See Continuation Page LIC 9099-C. Unsubstantiated The investigation revealed the following: regarding the allegation “Facility staff are not preventing a resident from harassing other residents.” It is alleged facility staff are not preventing a resident from harassing other residents in care. On 05/29/2025, LPA Ramirez interviewed staff and residents. Five (5) out of seven (7) resident interviews revealed R4 makes inappropriate comments towards residents, yells at other residents’ and has blocked a resident from access to parts of the facility. Resident interviews also revealed that staff intervene and address the situation. Three (3) out of the three (3) staff interviewed denied the allegation. Two (2) out of the three (3) staff interviewed revealed R4 does have inappropriate behavior towards staff and other residents, however staff intervene and redirect R4. One staff member reported that R4 has been spoken to regarding violating house rules and R4’s physician is notified of any incidents involving R4. On 05/29/2025, LPA Ramirez conducted a review of residents and unusual incident reports dated 01/15/25, 03/06/25, 04/15/25, 04/30/25, 05/15/25, 05/16/25, 05/21/25, written warnings dated 05/25/22 and 06/06/22, Incident Report Short Forms dated 05/08/22, 05/12/22, 05/22/22, 05/19/22, 06/01/22, 06/03/22, 06/06/22, 06/08/22, and the Residency Admission Agreement dated 06/02/2021, including facility house rules. The investigation revealed that R4 was admitted to the facility in June 2021, and since being admitted to the facility, R4 has exhibited inappropriate behaviors, such as making inappropriate remarks and/or sexual comments to other residents’, verbally abusing residents, throwing liquids/food on the floor, and preventing a resident from accessing parts of the facility. On 06/15/2022, staff met with R4 to discuss R4 inappropriate behavior towards staff and regarding R4s violation of the house rules due to smoking in residents’ room. On 06/06/22, the facility issued a written warning to R4 not verbally abusing staff. On 05/22/22, the facility issued a written warning to R4 not following the house rules as R4 was yelling at staff and throwing food onto the facility floor. Review of the House Rules which are part of R4s signed Residency Agreement dated 06/02/21, indicate that residents are to respect others in the community, including other residents, visitors and employees. However, the Residency Agreement/House Rules do not indicate what the facility will implement if a resident breaks the House Rule. Staff address R4’s behaviors and staff are intervening when issues arise between residents’ and R4. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 28-AS-20250522134243

Allegation investigated: Staff did not prevent an altercation between residents in care.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced initial 10-day investigation visit. LPA Cota met with Priscillla Gaytan and the purpose for the visit was explained. The investigation consisted of the following: On 7/9/25, LPA Cota, toured the facility, obtained copies of client and staff rosters, conducted interviews with Residents #1-10 and Staff #1-7. Resident record review was also conducted and copies of relevant documents were also obtained. ****Continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Regarding allegation: Staff did not prevent an altercation between residents in care. It is alleged that staff witnessed an incident between residents in which residents were shouting and using racial slurs, and that staff did not prevent the altercation from happening. Staff #1-7 (S1-S7) deny the allegation. Interviews with S1-S7 revealed, although residents sometimes are involved in verbal altercations between each other, staff are taking measures to prevent incidents from escalating. S1-S7 stated, they intervene by redirecting residents into regulating their frustrations with open communication and by guiding them into expressing their feelings appropriately. Staff also stated residents are encouraged to report incidents so that they are handled immediately by staff. Nine (9) out of (10) resident interviews indicated, verbal altercations occur between residents; however, they know they can express their concerns to staff and staff will talk to residents exhibiting verbal aggression. Nine (9) out of (10) residents interviewed stated; staff take measures to prevent verbal altercations from escalating into physical aggression between residents by talking to parties involved on a one to one basis, privately. Residents stated, staff encourage residents to report any type of aggression to administrative staff. Residents also stated, although verbal altercations are common among residents, staff intervene to calm the situations which have not become physical. Staff and resident interviews, do not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Priscilla Gaytan, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 28-AS-20250630141209

Allegation investigated: Staff did not ensure resident was allowed to be readmitted to facility

Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Administrator Priscilla Gaytan and discussed the purpose for todays visit. Investigation consisted of: staff roster, resident roster, residents discharge papers, ID page, physicians reports, interviewed staff #1, and requested specific documents from resident 1 files, attempted to interview resident #1. Investigation revealed: Regarding allegation:Staff did not ensure resident was allowed to be readmitted to facility. LPA Wesley spoke to the Administrator Priscilla Gaytan and she informed me that the facility did take the resident back, They are located in the memory care unit, LPA Wesley and the Administrator walked to the memory care unit and LPA greeted the resident and asked the name. They said they are resident 1. LPA Wesley spoke to staff 1 and she said there must have been a misunderstanding, they took the resident continued on LIC 9099C Unsubstantiated back and she was asking if they knew of a place that can assist the resident with a higher level of care, because of their aggressive behavior which can be a hazard for the staff and the other residents in care, and the resident is a fall risk, he can barely walk and he often falls. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was given to the Administrator Priscilla Gaytan.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 28-AS-20250613111812

Allegation investigated: Staff do not ensure smoke detectors in resident rooms are operating properly

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Esmeralda Ramirez Assistant Administrator and explained the purpose of the visit. Administrator Priscilla Gaytan arrived shortly. The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster, resident roster, and two months of maintenance request orders. LPA did a random room check of three(3) bedrooms upstairs and three (3) bedrooms downstairs. LPA conducted interviews with Administrator, staff 1- staff 3 (S1-S3), and resident’s 1 – 3 (R1-R3). SEE 9099C Substantiated In regard to the allegation” Staff do not ensure smoke detectors in resident rooms are operating properly”, It is alleged that smoke detectors on second floor are not working. The investigation revealed that during the time of visit LPA Gutierrez observed three (3) out of the six (6) smoke detector not in working condition. During interview with staff, it was revealed that work orders were submitted, and the issues were resolved to their knowledge. S2 stated that he/she has been having issues with second floor detectors and that they are being changed out with new ones. During interviews with residents three (3) out of three (3) did not have any issues with smoke detectors. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator Priscilla Gayton. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 28-AS-20250606105107

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 11, 2025

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on physical plant observations during the visit on 06/10/2025, three(3) out of six (6) smoke detector were not working. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: Administrator agreed to: 1. Fix or replace smoke detectors that were not working and submit video to LPA by POC due date. 2. Administrator will check all rooms occupied by residents to ensure all smoke detectors are working and send LPA a signed log stating they were checked.

Allegation investigated: Facility staff are not preventing a resident from harassing other residents.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 05/29/2025, regarding the above allegation. During today’s visit, LPA Ramirez was greeted by Social Services Assistant Gabriela Urrutia and Assistant Administrator Karen Meacham explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 3 interviews (S1 – S3), Resident#1-7 Interviews (R1-R7), Copies of resident#4 (R4) recent physician’s report, admission agreement, special incident reports, and physical plant tour. SEE 9099-C. Unsubstantiated The investigation revealed the following: regarding the allegation “Facility staff are not preventing a resident from harassing other residents.” It is alleged facility staff are not preventing R4 from harassing other residents in care. On 05/29/2025, LPA Ramirez conducted seven (7) resident interviews and three (3) staff interviews. Resident interviews and staff interviews conducted did not corroborate this allegation. On 05/29/2025, LPA Ramirez conducted residents records review. Residents records reviewed did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 29, 2025 · control 28-AS-20250522134243

Allegation investigated: Staff are not safeguarding residents personal belongings.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day complaint visit for the allegation listed above. LPA met with Kaitlin Antunez, Receptionist and explained the purpose of the visit. At 10:30am, Priscilla Gaytan, Administrator arrived and assisted LPA. The investigation consisted of the following: LPA obtained copies of Resident and Staff Rosters, Staff in-service training regarding residents rights/safety, room safety & room cleanliness (03/03/2025), theft & loss policy and screenshot of the report of the missing items by R1's family member. LPA also conducted a tour of facility and common areas. LPA reviewed and obtained files for Resident #1 (R1) such as Identification and Emergency Information Sheet, Residency Agreement (05/01/2024), Physician's Report (11/19/2024), Resident Appraisal, Resident Personal Property and Valuables Sheet and Inventory List and Individual Service Plan (ALW). Between 10:35am-12:30pm, LPA interviewed Resident #1 (R1) - Resident #13 (R13) and Staff #1 (S1)- Staff #5 (S5). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation:“Staff are not safeguarding residents’ personal belongings.” It is alleged that R1 has had small things missing from her room over the last few months and that staff don't always lock the door after performing the safety check, and that R1’s door is unlocked when she comes back from shopping. Interviews conducted with (5) out of (5) staff members stated that in-service training regarding resident safety, resident rights, theft & loss and room safety/cleanliness are being conducted to staff members regularly. All staff interviewed stated that there have been no issues or complaints brought to their attention regarding missing items from residents and doors being left unlocked lately. However, S1 stated that on 01/29/2025, R1's family member reported to S1 that R1 was missing some of her personal belongings that happened on 01/05/2025 between 2am and 11:30am. S1 reviewed the video footage based on the time frame given to them and did not find any signs of theft during their internal investigation. As a precaution, S1 recommended a lock box for R1’s items, but R1 declined. Some staff interviewed also stated that some residents would report that they are missing items, although residents forget where they placed them and later finds the items. S2 stated that she conducts room safety training to staff on a monthly basis and will continue to remind the housekeeping staff to ensure that regardless of the residents’ presence, they must secure/lock the residents’ doors after performing safety checks if the residents prefer their rooms locked. A total of 13 residents were interviewed, (12) out of (13) residents interviewed indicated that they do not have any issues with lost belongings and they feel safe living in the facility. Interviews conducted with (12) residents revealed that the facility staff respect their belongings and have never taken any of their belongings. Interview with R1 stated that some of her minor items had gone missing over time, but no cash or jewelry was lost. Interview conducted with W1 indicated that W2 did not want to seek reimbursement for R1’s missing items. LPA observed that residents have a key to their room and some residents keep their door opened and/or unlocked. LPA also observed that R1 occupies a private room on the 2nd floor, without a roommate and there are cameras in the hallways and common areas. Based on record review, the alleged missing items are not listed on R1’s personal Inventory list and that there was no police report filed for the missing items.Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Priscilla Gaytan, Administrator.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 28-AS-20250314143441

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Priscilla Gaytan and explained reason for visit. The facility is licensed to serve (343) older adults, ages 60 and over. There is a fire clearance approved for (343) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (30) residents. There are currently (10) residents receiving hospice care. LPA observed the physical plant, reviewed residents' medications, observed food supply, and reviewed staff and resident files. Resident bedrooms were randomly chosen for review. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.3 - 107.8 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating areas for the residents located around the facility. Passageways and exits are free of obstruction. LPA reviewed 10 resident records to confirm emergency contact is updated and residents have health screenings on file. 10 staff records were reviewed to confirm health screenings with TB, CPR training and fingerprint clearances. LPA reviewed 5 residents' medications. Medications are documented properly and stored in a locked office. Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff did not distribute resident's medication as prescribed.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegations. LPA met with Annadelle Padua/S-1 and discussed the purpose of today’s visit. During this visit, LPA obtained a copy of the staff and resident rosters, interviewed Staff #1 (S-1) through Staff #6 (S-6), interviewed Resident #1 (R-1) through Resident #5 (R-5), obtained a copy of the as needed (PRN) medication log administered on 12/31/24, a list of residents that frequently request as needed (PRN) medication and reviewed R-1’s file and obtained relevant documentation. LPA attempted to interview Resident #6 (R-6) and Resident #7 (R-7). Both R-6 and R-7 refused to be interviewed. Refer to LIC LIC9099C for the continuation of this report. Substantiated Allegation: Staff did not distribute resident's medication as prescribed. It has been alleged that on 12/31/24, R-1 called staff and requested R-1’s pain medication and was not provided with the medication. (4) out of (6) interviewed staff indicated that they recalled R-1 recently requesting R-1’s pain medication but were unable to provide the date nor time of the request as there are numerous residents that request their as needed (PRN) medications daily. (2) out of (5) interviewed residents indicated that they have recently requested their as needed (PRN) medications and were not provided with their request. Documentation reviewed revealed that on 12/31/24, R-1 was provided with Baclofen 10mg and Ibuprofen 600mg at 3:01 A.M. and 8:17 A.M. for pain. Per documentation, on 12/31/24, R-1 was not provided with another dose of the above noted medications. Per R-1’s physician’s order, both Baclofen 10mg and Ibuprofen 600mg are to be administered TID (every 8 hours) for pain as needed. R-1’s medication administration log indicated that both medications were administered in less than (8) hours and the log does not include the “reason” nor “result” of the administered medication. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 9099D. Exit interview, appeal rights and a copy of this report was provided to Priscilla Gaytan.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 28-AS-20241231151353

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 8, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self- administered medications as needed. This standard is not met at evidence by: Per medication log, R-1 was provided with both PRN medications in less than (8) hours (ordered for TID/every (8) hours) and the log does not include the “reason” nor “result” of the administered medication.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Administrator to submit a written statement which includes a plan on staff training pertaining to PRN medication administration to LPA Irra by POC date 01/08/25. Administrator to ensure staff training in this subject is completed within (2) weeks.

Allegation investigated: Facility staff leave residents in urine soaked clothing for an extended period of time. Facility staff did not provide resident with linens in good clean condition.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 01/03/2025 regarding the above allegations. LPA Gutierrez conducted an unannounced initial complaint investigation visit on 12/19/2024, and a needs further investigation was documented. LPA was greeted by Administrator Priscilla Gaytan and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 7 interviews (S1 – S7), Interview of Resident#1-10 (R1 – R10), Incontinence resident roster, and physical plant tour. SEE 809-C Unsubstantiated The investigation revealed the following: Regarding allegations: Facility staff leave residents in urine soaked clothing for an extended period of time- It is alleged facility staff leave residents in urine soaked clothing. Ten (10) out of ten (10) residents interviewed deny this allegation. Seven (7) out of (7) staff interviewed deny this allegation. During resident interviews, LPA Ramirez observed residents to be well groomed, clothing appeared to be neat and clean, and resident rooms were not observed to be malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility staff did not provide resident with linens in good clean condition- It is alleged facility staff do not provide residents with clean linen. Ten (10) out of ten (10) residents interviewed deny this allegation. Seven (7) out of (7) staff interviewed deny this allegation. LPA Ramirez toured ten (10) resident rooms at random. During tour, LPA Ramirez observed ten (10) out of ten (10) resident rooms to contain required linen. Linen appeared to be clean and not malodorous. LPA Ramirez observed signs posted on the inside or each resident room indicating when personal laundry and linen will be washed by housekeeping. LPA Ramirez observed a linen and personal laundry schedule in the facility laundry room. LPA Ramirez observed extra linen and bedding in the facility laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were observed during this instigation complaint. Exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 28-AS-20241211143313

Allegation investigated: Staff are refusing to allow resident to have access to their personal belongings. Staff did not safeguard resident's personal belongings. Staff did not accord privacy to resident.

Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with (Licensed Vocational Nurse) LVN Supervisor, Anne Graves. The investigation consisted of: LPA conducted interviews with LVN Supervisor, Anne Graves, Staff #1 (S1) to Staff # 5 (S5), and Resident #1 (R1) to Resident #13 (R13). LPA also interviewed the Assistant Administrator, Karen Meacham, and Staff #6 (S6) over the phone on today’s visit. LPA also requested copies of Staff and Resident Rosters. LPA requested R1 personnel file document: Identification and Emergency Information, Face Sheet, Physician's Report, Admission Agreement, Client/Resident Personal Property and Valuables, House Rules, Facility notes. LPA also requested staff training logs. Unsubstantiated The investigation revealed the following: Allegation: Staff are refusing to allow resident to have access to their personal belongings. According to the allegation, staff will provide access to the personal belongings when R1’s room is fixed to the staff’s liking. It is alleged that R1’s personal belongings (toiletries, pajamas, clothing, bedding, shoes) were taken out of R1’s room by facility staff and stored in another room in which facility staff is refusing to allow R1 access to R1’s belongings due to the staff stating that R1’s room is cluttered. Based on interview of the Assistant Administrator, LVN Supervisor, and six (6) out of six (6) staff all stated that the facility must follow safety protocol and ensure that residents and staff are kept safe from injuries, fire hazards and trips. All staff interviewed also indicated and provided information confirming to the LPA that R1’s room was unsafe, unsanitary, and had no clear passageway in case of emergencies. Interviews conducted with twelve (12) out of thirteen (13) residents denied the above allegation and have never had been in a situation where they were refused access to their personal belongings due to the room being cluttered. Based on record review, facility’s House Rules were provided to R1 and signed on the date of admission: 06/28/2024 which states ‘use the unit as your private residence and will maintain it in a clean, sanitary and orderly condition.’ The House Rules also states ‘Residents may not maintain their units in a manner that creates or presents a fire hazard, including but not limited to the storing of belongings in an excessive or unsafe manner, the obstruction of exists or passageways, or the storing of flammable or combustible materials. Based on interviews conducted, LPA was provided information that indicated that R1 was given a key to the room where R1’s personal belongings are and R1 has access to the personal belongings. S6 stated that R1 was allowed access to R1’s personal belongings on 12/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation. Allegation: Staff did not safeguard resident's personal belongings. It is alleged that when R1 was out of the facility, staff entered her room and took R1’s personal belongings and stored in another room strewn with other resident’s belongings in a mixed and disorganized way. Interviews conducted with twelve (12) out of thirteen (13) residents denied the above allegation and stated that they believe their personal belongings are kept safe. However, based on the observation, R1 is provided a key in a locked room so the personal belongings are secure. Per resident file reviews, staff maintain records of the resident’s personal belongings and have a facility theft and loss program document on file. LPA also requested and reviewed monthly training logs on topics of HIPPA, Resident Rights, Resident Dignity on file from 02/08/2024 to 08/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation. Allegation: Staff did not accord privacy to resident. It is alleged that a facility staff went into the resident’s room without consent from R1 for the purpose of taking personal belongings to create a safe environment and clear passageway. Based on staff interviews, R1 was received multiple verbal warnings to clean her room. The reason was due to safety concerns regarding the clutter and no clear pathway inside the room. During today’s visit, LPA observed the room and a clear pathway. LPA observed there was minor improvements of cleanliness but room does appear cluttered. Interviews conducted with the Assistant Administrator, LVN Supervisor and six (6) out of six (6) staff revealed that the facility staff deny the above allegation and respect resident’s privacy. Interviews conducted with twelve (12) out of thirteen (13) residents all deny the allegation and stated that they believe to be accorded privacy from the staff. LPA also reviewed monthly training logs on topics of HIPPA, Resident Rights, Resident Dignity on file from 02/08/2024 to 08/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation. Based on LPA observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted with LVN Supervisor, Anne Graves and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 28-AS-20241209140014

Allegation investigated: Staff did not allow the resident to fully participate in planning their care.

LIcensing Program Analsyt (LPA) Alberto Lopez made an unannonced visit to investigate the above alegation. LPA was greeted by Staff Bianca Castillo and Admiistrator Priscilla Gayton arived a short time later and asssited with the visit. The investigation consisted of Interviews with four (4) staff (S#1-S#4) and ten (10) residents (R#1-R#10) LPA reviewed and obtianed resident and staff rosters, current medication list for R1, medication list dated 2022 for R1, and Physician's report for R1. The investigation revealed: Allegation Staff did not allow the resident to fully participate in planning their care. It is alledged that that his doctor prescribed a second psychiatric medication against resident wishes. (Continued 9099C) Unsubstantiated (Continued from 9099) LPA interviewed four staff (4) and four (4) of four (4) staff denied the allegation. LPA interviewed ten (10) residents and nine (9) of ten (10) were not able to corroborate the allegation. S1 stated that facility has always includes residents in their care planning. S1 stated resident brought this issue to S1 in November 2024 and told S1 that R1 did not want to take the medication and S1 told resident that R1 has right to refuse any medication and S2 called R1 MD to discontinue the medication. LPA interviewed R1 and R1 stated R1 does not recall specific details, but stated that R1 was given a psychotropic medication, that S2 identified as Amitriptyline, since 2022 that R1 never agreed to. R1 stated R1 did not recall the medication name but R1 stated that it is on a list in R1 file. R1 stated that when R1 started getting the medication back in 2022, R1 asked S2 what the medication was for and was told it was for ulcers and stomach pain. R1 stated R1 did not have ulcers. R1 stated to LPA that R1 does not have clear recollection of details and continued to take the medication until one day R1 decided to take R1 list of medications to a local pharmacy and was told what Amitriptyline was for. R1 asked S1 for it to be discontinued and it was discontinued by his physician. R1 was inconsistent in R1 statements and could not provide any evidence to support the allegation that staff lied to R1. S2 stated R1 was already prescribed Amitriptyline medication before S1 even began work at facility which was three years ago. S2 denied ever telling R1 that Amitriptyline was for pain and ulcers. S2 stated S2 told R1 that Amitriptyline was for depression. S3 denied ever telling R1 anything about Amitriptyline. S3 stated it was never discussed with resident because resident did not bring it up to S3. There is no evidence that staff lied to resident. Based on interviews, most residents stated they participate in their care plan and know what medications they take and the reason they take them. There is insufficient evidence to substantiate this allegation. Based on statements and interviews conducted with staff, residents, and review of client file, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 28-AS-20241205092915

Allegation investigated: Staff left a resident unattended. Staff did not ensure a resident's alert device was properly operating. Staff did not properly report an incident involving a resident. Staff overcharged a resident for services not received. Resident sustained unexplained injury while in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Prisicilla Gaytan. An initial complaint visit was conducted on 7/23/2024, consisting of a physical plant tour of the interior common areas and resident (R1's) room. The call light system in R1's room was tested, and pictures of R1's injuries were taken. Staff (S1- S6) and resident (R1) were interviewed. Copies of the following documents were obtained: Resident (R1's) [Admission Record/Identification and Emergency Information, Residency Agreement, Individual Service Plan & Preferences, Physician's Reports [6/18/24 & 4/9/2019], Resident Appraisal, Head-to Toe Assesment dated 7/18/24, six (6) incident reports, Charting Notes, Plan of Operation/Fall Risk Plan, and staff and resident rosters were obtained. Photographs of R1's injuries were obtained. During today's visit, records were reviewed and a copy of the updated Residency Agreement "Addendum to Rental Agreement" and 7/17/24 staff assignment schedule were obtained, a physical plant tour of the AL and Memory Care Unit was completed, and residents (R2- R11), R1's authorized representative, and staff (S1 & S8) were interviewed. Substantiated Allegation: Staff left a resident unattended. It was reported that 95 year old resident fell in the bathroom on 7/17/2024 between the hours of 10PM -11PM, and laid on the floor for hours until morning the next day. A total of 7 staff were interviewed. The staff person that was in charge of R1's care during the NOC shift on 7/17/24 no longer works at the facility; therefore, was not interviewed. According to staff interviews, resident (R1) was found on the floor the next day (7/18/2024) at approximately 7:30 AM. The resident returned to the facility the same day of the fall, after completing rehabilitation orders following a hip replacement surgery in June 2024. Based on observation, resident rooms have pull string signal system in the resident's room and bathroom, and also provide a hanging or wrist pendant to residents. Resident (R1) was wearing the signal system wrist pendant at the time of the fall. However, the wrist pendant was inoperable. The resident was not able to reach the signal pull strings in the room due to injuries. Caregiver responsibilities include checking on residents every 2 hours, or 30 minute to 1-hour checks after resident's return from the hospital because residents may be weaker or have changes in condition. A total of 11 residents were interviewed, of which 5 residents stated that NOC shift staff sometimes take 45 minutes to 1 hour to respond to signal system. On 7/23/2024, LPA tested R1's signal wrist pendant and it was not operable. The findings reveal that R1 fell and none of R1's attempts to receive assistance were answered, and staff did not check on the resident between the hours of 10 PM - 7:30 AM. Based on record review, there is no documentation that R1 was being checked more frequently after returning from the hospital, nor whether the NOC shift caregiver (S8) was aware that the resident had returned from the hospital. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure a resident's alert device was properly operating. It is alleged that R1 was not able to receive staff assistance or medical attention in a timely manner after falling in the room. The resident attempted for hours to call staff for assistance by pressing the bracelet/watch pendant, but it was not working. On 7/23/2024, LPA tested the wrist pendant and confirmed it was not operating. Staff interviewed stated the signal pull strings in resident rooms and bathrooms work, but stated that some residents had been provided wrist or hanging neck pendants for use. However, staff stated that they failed to check on wrist/neck pendants regularly, and were unaware that they were not operable. Resident interviews revealed, that not all residents were given or use wrist/neck pendants, but had heard residents complain to Administration staff that the wrist/neck pendants were not operating properly. During both visits, the signal system was tested. It was observed that the Memory Care Unit signal system is separate from the Assisted Living area of the facility. This facility does not have signal system pagers that alert staff on duty when a resident requires assistance. Based on observation, there is sufficient evidence to corroborate the allegation. Allegation: Staff did not properly report an incident involving a resident. It is alleged that resident (R1's) authorized representative was not notified of the fall incident that occurred on 7/17/24, and discovered the next day 7/18/24, at approximately 7:30 AM, until later in the day after a Kaiser Permanente Physical Therapist (PT) visited the resident and observed bruises in knees, arms, and upper body. The PT notified facility nurses to call R1's MD. Based on record review, staff completed a "Head-to Toe Assessment" at 11:30 AM. LPA reviewed facility charting notes, and there was no documentation of R1's fall or notification to physician or responsible party. The incident report obtained does not list the time responsible party or MD were contacted. Once facility staff notified R1's MD, it was recommended that R1 be transported to the emergency room for x-rays. A total of 11 residents were interviewed, all stated that facility staff notify their responsible parties. However, in this case R1's responsible party was not notified right after they addressed the resident's fall. The resident's family received a call from staff notifying them that MD advised for the resident to be evaluated at the emergency room, many hours later after the fall incident. Staff protocol is to call facility nurse after fall, then paramedics, and after the medical emergency has been taken care LVNs are to notify family. There is sufficient evidence to corroborate the allegation. Allegation: Staff overcharged a resident for services not received. It was reported that resident (R1's) authorized representative met with Administration staff the day (7/17/24) the resident returned to this facility after discharge from a rehabilitation facility. It was agreed that a new additional personal care rate in the amount of $550.00 would be charged for incontinence care, bathing assistance, escort assistance, and more frequent checks due to post surgery hospitalization, effective 7/17/2024. Staff stated that caregivers meet daily with LVNS to report changes in condition of the residents, but in this case when the resident returned to the facility they did not obtain discharge paperwork from the family. Administrator stated that staff began providing ADL assistance in April 2024 without charge when they observed decline, but family had not agreed to pay extra for the services. However, the findings indicate that family signed an Addendum to Rental Agreement for personal care the afternoon of 7/17/2024, with an understanding that R1 would be checked on more frequently than every 2 hours, because the resident returned from a higher level of care facility. Since, the resident fell the same day they returned to the facility and laid on the floor for hours, and after the authorized representative agreed to an increase in rate, there is sufficient evidence to corroborate the allegation. NOTE: Resident (R1's) authorized representative was refunded the pro rated personal care rate paid by the family. Allegation: Resident sustained unexplained injury while in care. It is alleged that resident (R1) sustained a hip dislocation i.e the hip replacement came out of the socket, when the resident fell on 7/17/2024. According to information obtained, the fall resulted in multiple bruising/scrapes in knees, arms, chest, and throughout R1's body. Staff acknowledged observing bruising on knees and arms, but the Head-to-Toe Assessment did not document bruising on the arm or hip bruising/redness. LPA obtained an x-ray photograph of the injury caused by the fall. It shows the the metal socket completely dislocated. The resident had to undergo another hip replacement surgery as a result of the major injury. The resident never returned to the facility after the 2nd hip replacement surgery and was discharged from the facility on 8/30/24. There is sufficient evidence to prove R1's injuries were a result of neglect of care. Based on interviews conducted, record review, and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights will be provided via email and mailed to facility Administrator Priscilla Gaytan because of printing issues.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 28-AS-20240722091157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 2, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the findings indicate care staff did not conduct at the very least 2 hours checks after returning to the facility on 7/17/24, which resulted in R1 falling and laying on the floor unassisted for hours. This posed an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator agreed to submit a plan of correction that states staff responsibilities after residents return from higher level of care discharges, protocols in place, and proof of staff-in service training, which includes staff signatures. Submit written plan by tomorrow and proof of staff training by 10/4/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(C) · Plan of correction due date: Oct 2, 2024

Maintenance and Operation. Facilities shall have signal systems .... All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Identify the specific resident living unit. Based on physical plant observations during the visit on 7/23/24, R1's signal wrist bracelet was not working. The resident relied on the wrist alert system, which was inoperable on 7/17/24. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator agreed to: 1. Submit a written POC stating how the deficiency will be corrected by tomorrow. 2. Proof of staff in-service due 10/4/24. 3. Proof that the entire building's signal system, wrist/neck pendants were tested and are operational is due 10/4/24. ***NOTE: LPA observed: 1.The Memory Care Unit has a separate signal system in place, with staff having to run to the signal system room when rooms cannot be identified. 2. Facility staff do not use signal system pagers.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 4, 2024

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met evidenced by: This requirement was not met evidenced by: Based on record review and interviews conducted staff did not notify R1's responsible party of R1's fall incident (7/17/24), until late afternoon 7/18/24, after Kaiser PT staff notified LVNs of injuries observed, which posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator agreed to provide in-service training regarding 87468.1 and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 4, 2024

Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met evidenced by: Based on record review, on 7/17/24 R1's authorized representative met with staff and signed an Addendum to the Rental Agreement, that stated the resident would be receiving personal care services, and more frequent checks after return from a higher level of care facility.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator agrees to submit proof of: 1. Staff training addressing protocols after residents return to the facility. 2. Change of condition procedures/documentation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 2, 2024

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on interviews, photographs, and record review, the findings indicate that R1 dislocated the hip after falling on 7/17/24, and did not receive medical attention until late 7/18/2024, because staff did not perform a thorough body check, which posed an immediate health and safety risk.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administration staff agrees to submit a written plan that states how the deficiency was corrected by tomorrow, and proof of staff training by 10/4/2024.

Allegation investigated: Facility does not have sufficient staff to meet resident needs.

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator Priscilla Gaytan and explained the reason for the visit. The investigation consisted of: On 06/25/24, LPA Gonzalez conducted interviews with Administrator Priscilla Gaytan, and R1-8. LPA obtained copies of Staff and Client Rosters, Pest Control Invoices for May - June 2024, Resident Memo, shower schedules, and housekeeping schedules. LPA additionally conducted a tour of facility dining room, lobby, medication room, laundry room, patio, memory care unit (random rooms/private bathrooms - total of 5), public restroom and assisted living resident rooms (6 rooms/ bathrooms). On 09/05/24, LPA requested and received copies of Staff/ Resident Rosters and conducted interviews with Administrator Priscilla Gaytan, R9-12 and S1-7. LPA also collected copies Staff schedules for June 2024 – August 2024. Substantiated Investigation revealed the following: Regarding allegation, Facility does not have sufficient staff to meet resident needs, it is alleged that due to a lack of staff that has been going on for several months, there have been multiple issues in the facility's memory care and assisted living areas. Interview conducted with facility administrator revealed that there have been staffing struggles in the last few months. She stated that some staff quit and there have been many staff call outs. She stated that they outsource a staffing agency as well as offer overtime as well as implement mandatory overtime. Interviews conducted with 7 out of 7 staff revealed that there is not sufficient staff to property meet resident needs. They stated that in order to ensure to meet resident needs they have to work overtime, or they have to work at a faster rate which can be stressful. Staff stated that some shifts are better than others, for example the day shifts are better staffed versus the night shifts. Interviews conducted with 7 out of 12 residents revealed that the facility does not have sufficient staff to meet their needs as they have observed the recent high turnover and how stressed the current staff at the facility are. 1 resident stated that due to the facility not having sufficient staff they have had to wait for over 30 minutes for toilet assistance. Based on interviews conducted with residents and staff which confirmed that the facility does not have sufficient staff, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held. A copy of the report and appeal rights were provided to Administrator Priscilla Gaytan. Investigation revealed the following: Regarding allegation, Staff are not dispensing medications as prescribed, it is alleged that facility residents are not receiving their medications on time, with delays of 20 minutes up to an hour. Interview with Administrator Gaytan and facility staff revealed that facility properly administer medications for all residents as prescribed and in a timely manner. Staff stated that once residents have taken their prescribed medications at the appropriate times they initial each individual resident Medication Administration Records (MARs) indicating that the medication was taken and if a resident refuses then the log will be initialed with the letter "R", if a resident is in the hospital the log will be initialed with the letter "H and if a resident is not in the facility, staff will also indicate on MAR log that the resident was out of the facility. Staff also stated that when a resident refuses their medications, they will attempt for the resident to take their medications and if they continue to refuse then they will properly initial the resident's MARs and will report the refusal to the administrator. Facility staff stated that they ensure on a daily basis that residents take all prescribed medications. Interviews conducted with 11 out of 12 residents revealed that facility staff ensure daily that they are getting their medications as prescribed and that they get their medications at the appropriate dosage times. They stated that they have not experienced any delays of 20 minutes to an hour to get their prescribed medications. 1 out of 12 residents stated that they have waited as long as 30 minutes to get their prescribed medications. LPA reviewed client MARs records and observed that medication is given to clients at correct times and then properly initialed by staff. LPA did not observe any discrepancies on MARs records that were reviewed. Based on interviews conducted with facility staff, facility clients, and LPA review of documents there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not meeting resident’s hygiene needs, it is alleged that facility residents are left in soiled diapers, leading to rashes and residents are not receiving proper hygiene care such as baths/showers. Administrator and staff that were interviewed denied the allegation. They stated that residents that require assistance with their Activities of Daily Living (ADLs) received adequate assistance to meet their hygiene needs on a daily basis for example residents are bathed twice a week, their diapers are changed every two hours and as needed, and they are assisted throughout the day with their ADLs. Staff denied that residents are left in soiled diapers leading to rashes. 7 out of 12 residents stated that their hygiene needs are met, they are receiving timely and scheduled showers, and their diapers are changed in a timely manner. 4 residents stated that they do not need assistance with their hygiene needs. 1 out of 12 residents stated that they do not receive a timely shower due to staffing shortage. Based on interviews conducted with facility staff, and facility residents there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not ensuring resident's room is cleaned, it is alleged that facility residents are not receiving room cleaning for weeks. Administrator and staff interviewed stated that resident rooms are cleaned daily. 11 out of 12 residents stated that their room is cleaned daily. 1 out of 12 residents stated that their room is cleaned daily but they are not satisfied with the thoroughness of the service. LPA conducted a tour of resident rooms in the memory care unit and rooms in the assisted living section of the facility and observed rooms to be clean or in the process of being cleaned. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not meeting resident’s laundry needs, it is alleged facility staff are not providing laundry services for weeks, staff are not providing clean linens and instead putting a blanket over dirty linens. Administrator and staff interviewed denied the allegation and stated that facility staff are meeting resident’s laundry needs. Staff stated that residents receive laundry services per their schedule which is one a week for all residents and as needed. 12 out of 12 residents stated that their laundry is done weekly and as needed and they do not have any concerns or complaints regarding their laundry needs. LPA conducted a tour of resident rooms and observed that residents had clean linen. LPA did not observe blankets covering dirty linens. LPA toured the laundry room and observed staff doing laundry. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not addressing mold at the facility, it is alleged that there is presence of mold in storage room B37. Administrator and staff denied the allegation and stated that there is not any mold in any room of the facility. Interviews conducted with 12 out of 12 residents revealed that they have not seen any mold in their rooms. LPA conducted a tour of facility dining room, lobby, medication room, laundry room, patio, memory care unit (random rooms/private bathrooms - total of 5), storage room B37, public restroom and assisted living resident rooms (6 rooms/ bathrooms) and did not observe any mold. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not ensuring that facility is free of pests, it is alleged that there are roaches in resident areas and in facility laundry room observed since April 2024. Interviews with 1 out of 12 residents revealed that they have observed roaches in their room and when they reported it to maintenance staff who provided treatment. 1 out 12 residents stated that they have observed water bugs. 10 out of 12 residents interviewed stated that they have not observed roaches. Interviews with Administrator and maintenance staff revealed that the facility is treated twice a month by pest control and denied that there are roaches in resident areas or the laundry room. 1 staff stated that they have observed dead roaches in the hallway and 1 staff stated that they have observed water bugs. During the tour of the facility, LPA did not observe any roaches or pests throughout the facility including resident rooms and laundry room. Documents reviewed revealed facility receives services twice a month and did not indicate any details of live pest activity. Based on interviews conducted with facility staff, facility residents, LPA observations and record review there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are not ensuring residents room does not smell like urine, it is alleged multiple resident rooms have a strong urine odor, and that staff and residents have complained to the Administrator without any improvements. Administrator and staff denied the allegation. They stated that in the morning there might be some strong scents coming out of resident rooms when staff are assisting a resident that might be incontinent, but the smell does not last after incontinent care. Staff stated that linens are changed after accidents and soiled linens and clothing are immediately taken to the laundry room to be washed. Staff also stated that rooms are cleaned daily and that included emptying out trash. 9 out of 12 residents stated that there are not strong odors like urine coming from resident rooms. 2 residents stated that there are strong urine smells at times when staff are assisting a resident with a diaper change. 1 out of 12 residents stated that there are some residents whose clothing smells like urine. LPA conducted a tour of memory care unit (random rooms/private bathrooms - total of 5), public restroom and assisted living resident rooms (6 rooms/ bathrooms) and did not smell any scents that can be described as strong urine odor. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Priscilla Gaytan.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 28-AS-20240620104438

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 24, 2024

87411 Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....for sixteen or more... This requirement is not met as evidenced by: Based on interviews conducted, staff and residents stated that facility did not ensure there is adequate staffing to tend to residents' needs in a reasonable amount of time which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Licensee to submit a written plan to LPA detailing how the current staffing level is able to meet the needs and support each resident's physical, social and emotional safety and healthcare needs and determine if additional staffing is required to ensure the facility is meeting Title 22 Regulation by POC due date. Administrator to submit an LIC500 and a breakdown of staff for each department by POC.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20240722091157. The purpose of the visit was explained to LVN Destiny Cazares. LPA interviewed resident (R1) in their room and observed three (3) medication pill bottles on top of the side table next to the recliner. LPA asked the resident a series of questions to determine mental function status. The resident was not oriented to time, day of the week, and was unable to recall the names of prescribed medications and dosage times. The resident stated "I need help with my meds. I don't remember if I took them. Please help me." LPA called LVN staff and the medications were removed from the resident's room. Per staff, medication management will be initiated and R1's responsible party will be notified. Staff shall follow-up with Primary Care Physician for change in condition. Per Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right 87465(h)(1)(B) Incidental Medical and Dental Care... Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. Deficiency was cited. Exit interview held with Destiny Cazares. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(B) · Plan of correction due date: Jul 24, 2024

Incidental Medical and Dental Care. Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met evidenced by: Based on observation during interview with resident (R1), 3 medications were observed on the resident's table next to the recliner. Resident stated they are confused and need help with medication management; resident could not recall the names or dosage times; which poses an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: LVN staff removed medications from R1's room, and will begin managing R1's medications. Administrator shall: 1. Submit written proof of correction and conduct staff training by tomorrow. 2. Notify responsible party of care plan changes 3. Follow-up with Primary Care Physician for change in condition

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to investigate the allegation listed above. LPA met with Jessica Camacho, recptionist for the facility, and explained the purpose of the visit. Administrator Priscilla Gaytan arrived shortly thereafter. The investigation consisted of the following:LPA interviewed Staff #1 - 5 (S1 - S5), Witness #1 (W1), obtained the resident roster, and also obtained the Physician's Report, Appraisal, FACE Sheet, Physicians Orders, and a Resident Discharge Summary for R1. The investigation revealed the following: In regards to the allegation "Illegal Eviction," it is alleged the facility illegally evicted R1 by discharging them to a hospital without issuing a 30-day eviction notice, and then refused to accept the resident back into the facility. Unsubstantiated During interviews with the staff members, four (4) out of four (4) did not corroborate the allegation. S1 stated that R1 was never served an eviction notice, but rather was transported to Norwalk Community Hospital on 6/14/2024 for a psychological evaluation due to R1's need for a higher level of care, which the Primary Care Physician (PCP) of R1 agreed with. S1 stated that R1 had been having increasing behavioral issues, including hitting and scratching the caregivers who attempt to assist R1 with their Activities of Daily Living (ADLs). S1 explained that R1 has since been discharged to a Skilled Nursing Facility known as Maywood Health and Wellness Center, and that discharge paperwork for R1 from San Dimas Retirement Center was signed by R1's POA on 5/19/2024. Other staff interviewed stated that R1 did exhibit increasing agitation, refused assistance with their ADLs, and that it was taking multiple caregivers at a time to assist R1. Upon record review LPA observed that there was a Physician's Order from R1's PCP that R1 requires a higher level of care. LPA also observed that on 6/19/2024, R1's POA signed a Resident Discharge Summary for R1. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240618092225

Allegation investigated: Facility is not ensuring that resident's transportation needs are being met while in care.

Licensing Program Analyst (LPA) V. Maldonado made an unannouced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Assistant Administrator, Priscilla Gaytan, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following records for Resident# 1 (R1): Facesheet, Physician's Report, and Needs and Services Plan. LPA also conducted interviews with with Staff#1-4 (S1-S4) and Residents#1-5 (S1-S5). The investigation revealed the following: Regarding allegation: Facility is not ensuring that resident's transportation needs are being met while in care. It is alleged that R1 requires transportation services to get to medical appointments due to R1's ambulatory status, however, R1 requests a large vehicle for transportation and does not get it, resulting in R1 missing medical appointments due to not feeling safe. Unsubstantiated Per staff interviews, (4) of (4) staff denied the allegation. They stated S2 assists with transportation arrangements and always requests for a larger vehicle, per R1's request. However, the transportation service sometimes sends what they have available. And if a smaller vehicle arrives, R1 refuses the service and misses medical appointments. Staff stated that on 4/29/24, transportation was arranged for R1 for a medical appointment. When a smaller van arrived, R1 refused the transportation. Staff stated that R1 has a manual wheelchair which could fit in the smaller van and R1 could be transported, but R1 refuses to use it as R1 claims it does not work well. S2 stated to have requested a bigger vehicle when arranging transportation, however transportation services stated they provide what they can. Per R1's Appraisal and Physician's Report dated 7/27/23, R1 does not require assistance with transferring/propelling in wheelchair. Per interview with R1, R1 admitted to refusing the transportation on 4/29/24 as R1 did not feel safe going in the smaller van. R1 states to hit their head going over bumps and returns in pain due to too much motion in the small van. R1 stated S2 promised R1 to get a bigger van for R1's medical appointments, however this is the second time this occurs. Per resident interviews, (4) of (5) residents denied the allegation. Residents interviewed stated that S2 assists them with arranging transportation services and have never had issues. Residents stated that once they are aware of their appointments, they inform S2 of it and their transportation is always arranged for the dates and times they need it. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is Unsubstantiated. An exit interview was conducted and copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2024 · control 28-AS-20240429151719

Allegation investigated: Staff do not address healthcare needs of resident. Staff allow resident to be left in soiled clothing for an extended period of time. Staff do not ensure resident is provided with fresh clean linens.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met Priscilla Gaytan, administrator and Anne Graves, LVN supervisor. LPA explained the purpose of today’s visit and discussed the allegations mentioned above. The investigation consisted of residents/ staff interviews, facility tours, and review of facility records. LPA obtained resident/staff roster, staff’s training records and residents’ facility files. The investigation revealed the following: In regards of facility staff do not address healthcare needs of resident, it is alleged staff do not address resident’s rash. LPA attempted but failed to interview resident#1 (R1). Per resident interviews, eight (8) out of ten (10) residents who were interviewed could not corroborate the allegation. Two (2) out of ten (10) residents declined to be interviewed. Resident interviews revealed that staff would conduct skin assessment weekly and address their healthcare needs to medical professional. (-continued in LIC 9099C-) Unsubstantiated Staff would check on them when changing their clothes or bathing them. Seven (7) out of seven (7) staff denied the allegation. Staff interviews revealed that staff would conduct skin assessment to residents, report the result to administrator and nurses, and provide care to residents accordingly. Per record review, staff would report skin assessment to LVN. Per observation, residents looked fine and decent. They were able to verbalize their skin issue. Therefore, there is not preponderance of evidence to show staff failed to address resident’s healthcare needs while in care. In regard to allegation staff allow resident to be left in soiled clothing for extended period of time, it is alleged that staff left resident in soiled clothing for extended periods of time. Per resident interviews, eight (8) out of ten (10) residents who were interviewed could not corroborate the allegation. Two (2) out of ten (10) residents declined to be interviewed. Resident interviews revealed that they had never left in soiled clothing. Staff changed their clothes timely if clothes got soiled. All seven (7) staff denied the allegation. Staff interviews revealed that staff would change residents’ clothes daily/ as needed. As LPA observed, residents looked clean and neat. Therefore, resident was not left in soiled clothing for extended period of time. In regard to allegation staff do not ensure resident is provided with fresh clean linens, it is alleged that staff do not change resident’s bedsheets. Eight (8) out of ten (10) residents who were interviewed could not corroborate the allegation. Two (2) out of ten (10) residents declined to be interviewed. Resident interviews revealed their bedsheets were changed daily, weekly or as needed when soiled. Staff changed residents’ bedsheets timely when after soiled. All seven (7) staff denied the allegation. Staff interviews revealed that staff would change residents’ bedsheet at least once weekly and/or as needed. Per observation, residents’ bedsheets and rooms were observed to be clean. Therefore, clean linens were provided to residents. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Anne, LVN supervisor. The findings were discussed. A copy this report was provided at time of the visit.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 28-AS-20240327143451

Allegation investigated: Staff did not provide adequate supervision resulting in resident speaking to another resident in an inappropriate manner.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit at the facility, for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Assistant Administrator, Priscilla Gaytan, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff rosters, and the following documents for Resident#1-2 (R1-R2): Facesheet, Physician's Report, Needs and Services Plan, and incident reports for the month of March 2024. LPA also conducted interviews with Residents#1-9 (R1-R9) and Staff#1-5 (S1-S6). The investigation revealed the following: (Report Continued on LIC9099-C...) Unsubstantiated Regarding allegation: Staff did not provide adequate supervision resulting in resident speaking to another resident in an inappropriate manner. It is alleged that on 3/18/24, while waiting for breakfast in the dining room, R1 was playing music loudly on a personal device, to which R2 got upset by, and resulted in R2 yelling profanities at R1. Per staff interviews, (7) of (7) of staff stated that R1 and R2 do not get along well. (5) of (7) staff interviewed admitted to the incident of a verbal altercation between R1 and R2 occurring, but denied it occurred due to to lack of adequate supervision. Staff stated that if they witnessed the altercation, they would have intervened and reported it to management. Per S1 and S2, R1 informed S1 of the incident and wanted to have the concern addressed. S1 addressed the concern by speaking with R1 and R2, and asking them to speak to each other to try to resolve the matters, but both residents declined. Per S1, R1 declined to stop playing their music during meal times and will continue to purposely do it "to prove a point." Per resident interviews, (3) of (10) residents admitted the verbal altercation occurred. R3 stated to have witnessed the altercation between R1 and R2, however, R1-R3 stated no staff were present to witness it. R1 stated to have been playing R1's music from their electronic device in the dining room, when suddenly, R2 got up and began shouting profanities at R1 solely for playing R1's music. R2 did not previously ask R1 to lower the music or turn it off. R2 admitted to cursing at R1 for having their music playing loudly and stated that it is "disrespectful" to play music while others are eating. R3 corroborated to the incident occurring this way. R3 stated that R2 was shouting "nasty and dirty" profanities at R1 and felt uncomfortable at the things R2 told R1. R3 stated that R1 stayed quiet while R2 shouted these things at R1. R1 then spoke up and told R2 something in R1's defense. (5) of (9) residents interviewed stated that R1 and R2 have had problems with one another for a few years now. Residents stated that management is aware of this and have tried to intervene, but the issues are ongoing for unknown reasons. Per the incident report obtained, dated 3/18/24, the incident involving R1-R2, and concerns addressed were reported to licensing on 3/20/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 28-AS-20240320152703

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Assistant Administrator (AA), Priscilla Gaytan, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with AA Priscilla, observed the facility food supplies, reviewed (7) resident medications, (7) resident files, (4) staff files and interviews were conducted with (4) staff and (7) residents. The facility is a two-story building with a memory care unit, operating as a Residential Care Facility for the Elderly. It is licensed to serve (343) older adults, ages 60 and over. There is a fire clearance approved for (343) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (30) residents. There are currently (5) residents receiving hospice care. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required. LPA observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water was tested and measured at 105*F-112*F, which is in compliance. The facility has a commercial kitchen. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 01/19/2024. The call system was tested in resident bedrooms and were operational. The facility is equipped with surveillance cameras in common areas. (7) resident files and (4) staff files were reviewed and observed to be complete with all required documentation. (7) resident medications were reviewed and were observed to be documented properly and given as prescribed. No deficiencies were observed or cited, during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 22, 2024

Allegation investigated: Staff does not provide adequate food service. Facility serves food of poor quality. Facility does not have enough staff to meet residents' needs. Residents are not receiving medication as prescribed. Residents' hygiene needs are not being met.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Priscilla Gaytan who assisted with today's visit. Regarding the allegation that : (1) Staff does not provide adequate food service, and the (2) facility serves food of poor quality, the investigation consisted of : interviews with Administrator and staff #1- staff #4, and resident #1 - resident #11, tour of the kitchen, review of facility food supply, and review of facility menu. Administrator and staff stated that staff do provide adequate food service. They stated that residents are served adequate portions of food, and they can request to get second servings as well. Administrator and Staff stated that the food served is of good quality. Residents interviewed were unable to corroborate the allegation(s). Eight out Eleven residents stated that the facility does provide adequate food service, and EIght out of Eleven residents stated that the food served is good quality. LPA reviewed food supply, and observed that the food appeared to be of good quality. LPA observed that the facility had a sufficient amount of perishable and non perishable food on today's visit. Unsubstantiated Regarding the allegation that : (3) the facility does not have enough staff to meet residents' needs, the investigation consisted of review of staff roster, and interviews with Administrator, staff #1- staff #4, and resident #1 - resident #11. Administrator and staff interviewed, denied the allegation. They stated that the facility has sufficient staff to meet resident needs. Residents interviewed were unable to corroborate the allegation. Nine out of Eleven residents interviewed stated that the facility has enough staff to meet resident needs. Review of staff roster, indicates that the facility has sufficient staff to meet the needs of residents. Regarding the allegation that : (4) residents are not receiving medication as prescribed. The investigation consisted of review of a portion of resident medication(s) and interviews with Administrator, staff #1- staff #4, and resident #1 - resident #11. Administrator and staff interviewed, denied the allegation. They stated that residents are receiving their medications as prescribed. Residents interviewed were unable to corroborate the allegation. Eleven out of eleven residents interviewed stated that they are receiving their medication as prescribed. Review of resident(s) medications, indicate that residents medications are being administered as prescribed. Regarding the allegation that : (5) residents' hygiene needs are not being met. The investigation consisted of interviews with Administrator, staff #1- staff #4, and resident #1 - resident #11. Administrator and staff interviewed, denied the allegation. They stated that residents who require assistance with hygiene, receive assistance from staff. Residents interviewed were unable to corroborate the allegation. Eleven out of eleven residents interviewed stated that either they do not require assistance, or if they do, they stated that they receive assistance from staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Copy of report provided to Ms. Gaytan.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 28-AS-20220523124939

Allegation investigated: Resident fell while in care sustaining in fracture. Staff did not seek medical attention to resident in a timely manner. Staff did not respond to resident in a timely manner.

LPA made subsequent visit to complete investigation for the above allegations. LPA met with LVN Supervisor Anne Graves and discussed purpose of the visit. LPA reviewed and obtained copies of staff and resident rosters, R15 Physician’s report for Residential Care facilities, R15 hospital discharged summary. Incident reports dated 07/19/2023 (2) LPA interviewed five Staff S#1-S#5 (S1-S5) and15 residents R#1-R#15 (R1-R15) The investigation revealed: Allegation: Resident fell while in care sustaining in fracture. It is alleged that resident sustained a fracture while in care. (continued on 9099C) Unsubstantiated LPA interviewed R15 and R15 explained that R15 was using the bathroom on 07/19/2023 at around 7:30- 8:00am and was attempting to back up coming out of restroom to sit on wheelchair and the wheelchair didn’t have the brakes on and it roll backed and R15 hit the floor injuring R15 hip and ribs. R15 stated it was not facility staff neglect or fault that R15 fell. R15 admitted that wheelchair brakes were broken and R15 should have never been using it since R15 had other wheelchairs R15 could have used. There is no evidence that facility was neglectful or was at fault for R15 fall. Allegation: Staff did not seek medical attention to resident in a timely manner. It is alleged that facility staff did not seek medical attention to client after fall. S3 stated she was first to assist R15 in the am and was alerted to R15 needing help by residents in the garden who congregate by resident’s room in the smoking area, and she assessed R15 and asked R15 if R15 would accept going to hospital. R15 refused to go to hospital at that time. S4 who was in training and shadowing S3 also stated that R15 refused to go to hospital when initially offered. R15 was offered pain medication at the time and according to S3, it was provided. R15 at first stated that R15 did not refused but then stated that R15 does not remember the events of the day and that R15 may have refused to go to hospital initially. S5 stated that his shift begins in the afternoon and that when he met up with R15 around 3:00-3:30pm, R15 asked to go to hospital and S5 contacted S3 and R15 was transported to San Dimas Community Hospital that afternoon. S5 stated that R15 never mentioned to him that he had asked staff to call 911 or to be taken to hospital earlier. There is not enough evidence to support that facility failed to provide medical attention to resident in timely manner. Allegation: Staff did not respond to resident in a timely manner. It is alleged that resident used the call light to get help and that S6 did not respond and get help for R15 for at least 30 minutes. LPA interviewed 5 staff and all 5 denied the allegations. R15 stated he pulled the call light at around 7:30 – 8:00 am and that it took a long time for front desk to get R15 assistance. S3, S4 and S5 stated that resident never mentioned he used call light and that no one from the front desk informed them that resident needed assistance. The front desk staff S6 was not available to answer questions and did not return LPA calls and no longer employed at facility. Facility does not keep logs of call light request. There is no evidence to substantiate this allegation. Based on the documents reviewed, interviews conducted with staff and residents, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20230724124405

Allegation investigated: Resident in care sustained unexplained injury. Staff denied authorized representatives to access resident records. Staff did not report incident to appropriate parties.

LPA made subsequent visit to deliver findings on the above allegaions. LPA met with LVN Supervisor Anne Graves and discussed he purpose of the visit. LPA reviewed and obtained R1 Physicians Report, other pertinant medcial infomation for R1, incident reports dated 09/25/2022 and 09/26/2022. Staff and residents rosters. LPA interviewed 7 staff, Staff #1-#7 (S1-S7) one (1) witness W#1 (family member), and 13 residents R#1-R#13 (R1-R13). LPA was unsuccessful in interviewing S8 after multiple attempts. The investigation revealed: Allegation: Resident in care sustained unexplained injury. It is alleged that resident in care had a fall on 09/25/2022 and facility could not provide explanation as to want transpired. Substantiated LPA interviewed 7 staff S#1-S#7 including administrator. On 9/25/22 two staff S4 and S8 were attempting to change resident when resident fell to the ground and hit R14 face on R14 wheelchair footrest that were removed from R14 chair and were by the beside. Administrator stated she was not at facility when incident occurred and does not know how R14 got injured. S4 who was in the room when the incident happened stated she was helping S8 to get the R14 to bed and R14 was very agitated and didn’t want anyone to touch R14. S4 and S8 were able to get R14 in bed from wheelchair and R14 continues to fight with staff and yelling at them to not touch R14. S4 stated R14 struck S8 after we changed R14, and I went to get a dress from R14 closet and had my back turned and heard S8 yell and turned around to see R14 on the floor and R14 had thinks R14 struck R14 face on the wheelchair footrest. S4 stated she did her report and does not recall if R14 went to hospital that day. Supervisor S2 stated R14 was in chair and fighting the staff while they attempted to change R14. S2 stated R14 was in chair when R14 fell and that she may have hit the wheelchair footrest on the floor. Supervisor S3 did not remember what occurred. S5 (temporary Administrator) stated she didn’t know what happened. S5 stated that daughter was told about incident but not the extent of the injuries and did not recall the date. S6 stated she did not know anything about the incident. LPA attempted to contact S8 on more than 3 occasions and was unsuccessful. S8 is no longer employed at the facility. There were several differing explanations of how the bruises and injuries had occurred but none that fully explained what happened. Resident 14 was hurt, staff failed to properly assess R14 injuries, seek medical attention and did not send R14 to hospital until the next day. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Allegation: Staff denied authorized representatives to access resident records. It is alleged that both the resident’s daughter and Ombudsman asked for residents records and were denied access to the records by facility. S6 admitted to LPA denying access to incident reports to Ombudsmen explaining that she was following legal advice from facility attorney. The daughter of R14 sent several emails requesting R14 medical record beginning on Oct 4th, 2022, and the facility did not provide them within 24 hours as required by regulations. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Allegation: Staff did not report incident to appropriate parties. It is alleged that the facility failed to report two incidents to appropriate parties. The facility failed to report the incidents to the Ombudsman when the Ombudsman requested incident reports. The Ombudsman had received authorization to act on behalf of resident and should have been able to review and obtain copies of the incident reports dated 09/25/2022 and 09/26/2022. Finally, on 10/25/2022 the two incident reports were emailed to Ombudsman Tam dated 09/25/2022 and 09/26/2022. LPA noted that the SIR from incident on 09/26/2022 was dated on 09/25/2022. CCL has a record of SIR from 09/25/2022 but no internal record that SIR from 09/26/2022 was reported to CCL. Facility could not provide proof that SIR dated 09/26/2022 was faxed over. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Based on LPA's observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted with Supervisor Anne Graves and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20230314164113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(2) · Plan of correction due date: Dec 19, 2023

87468.1 (2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Facility staff failed to properly observe R14 that resulted in fall with injury and failed to properly assess R14 after fall.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator to self certify that there is proper observation of Resident's when assistance is needed. Administrator to submit to Licensing a Staff Training in dealing with observation of residents and any changes physically, emotionally, and mentally. Plan to be submitted by 12/19/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Dec 19, 2023

Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The requirement is not met as evidenced by: Facility failed to communicate with family/responsible party promptly and appropriately after incident on 09/25/2023. Family was not notified about incident until the following day.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator shall ensure that family and responsible party of residents are informed in a timely manner. The licensee will write a letter to CCL explaining how this will be remedied and read section Title 22 section 87468.1(a)(8).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Dec 19, 2023

87211(a)(1)(d) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The requirement is not met as evidenced by: During the course of the investigation, LPA discovered that a special incident report was not submitted by the facility for incident for Resident #14 on 09/26/2022 according to Title 22 Reporting Requirements. Incident reports dated 09/25/2022 and 09/26/2022 were not provided to Ombudsman until 10/25/2022the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: The administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how facility will ensure that incidents are reported to the CCL office as required according by the Regulation. The administrator must also conduct in-service training to all staff in reference to Reporting Requirements and provide a copy of names and signatures of all staff in attendance of training. POC is due to CCL by 12/19/2022

Allegation investigated: Staff did not ensure resident had a clean mattress. Resident’s toilet was in disrepair.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegations. During today's visit, LPA Maldonado met with Assistant Administrator, Priscilla Gaytan, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant, and requested a copy of any recent plumbing invoices for repairs in the last month. LPA also obtained a copy of Resident# 1 (R1) Facesheet and Physician's Report, and conducted interviews with Residents# 1-10 (R1-R10) and Staff# 1-4 (R1-R4). The investigation revealed the following: Regarding allegation: Staff did not ensure resident had a clean mattress. It is alleged that when R1 was moved to a new room, a clean mattress was not provided. (4) of (4) staff interviewed denied the allegation. They stated that some residents bring their own furniture when they move in and some prefer the furniture that the facility. (Report continued on LIC9099-C...) Unsubstantiated Staff stated that any furniture that may be dirty, in disrepair, or in bad conditions are disposed of. During the inspection of R1's room, LPA observed R1's bed to have all the required linens, the mattress was in good repair and did not appear to be dirty. LPA also observed that R1's bed had a memory foam topper. Per R1, R1's family purchased it for additional comfort, however R1 stated to prefer R1's family purchase a new mattress altogether for R1. (6) of (10) residents could not corroborate the allegation. Regarding allegation: Resident’s toilet was in disrepair. It is alleged that on 11/26/23 and 11/27/23, R1's toilet was clogged and was in disrepair, and R1 had to use a garbage bag over a pail as a toilet. (4) of (4) staff interviewed denied the allegation. Per S3, R2 reported there was water leaking from the ceiling above R2's toilet (dates unspecified). S3 went to inspect and discovered that R1's restroom above R2's restroom was causing the leak. Upon repair, the leak in R2's restroom stopped. But, R1 did not report R1's toilet being in disrepair when S3 repaired the water leak. (3) of (4) staff stated that later that day, R1 reported R1's toilet was not flushing and appeared to be backing-up. Per interview with R1, R1 denied having to use a garbage bag over a pail as a toilet. The investigation revealed that R1 had access to the common bathroom, which was down the hall from R1's room. However, R1 chose not to use the common bathroom. R1 reported the toilet was fixed that same day by maintenance and a towel was pulled out from the toilet’s plumbing, which was causing the toilet to clog. Per staff, a copy of the repair invoice could not be provided, as there was no work order completed due to the issue being an emergency/priority. (6) of (10) residents interviewed could not corroborate the allegation. Based on LPA's observations and interviews conducted, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Assistant Administrator, Priscilla Gaytan, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2023 · control 28-AS-20231129140105

Allegation investigated: Staff behavior poses as a risk to a resident while in care. Staff do not provide adequate food service to a resident. Resident is not being treated fairly while in care. Staff are retaliating against a resident.

LPA Alberto Lopez made a subsequent unannounced complaint visit to deliver findings and met with Administrator Priscilla Gaytan and explained the purpose of the visit. The investigation consisted of interviews with Administrator and 5 staff (S#1- S#6) (S1-S6) and 13 residents (R#1-R#13) R1-R13. LPA toured the kitchen and obtained resident and staff roster as well as menus for the 2 weeks and alternate menu for residents who would like to substitute any items for lunch and dinner. R1 Physicians report. The investigation revealed: Allegation: Staff behavior poses as a risk to a resident while in care. It is alleged that resident became distressed due to interaction with Administrator and Assistant Administrator. That Administrator does not treat resident with dignity and respect which has caused resident to suffer emotional distress. 4 (continued on 9909C) Unsubstantiated LPA interviewed thirteen residents and 13 of 14 residents could not collaborate the allegation, 6 of 6 staff denied the allegation. Some staff stated that they are trained to be of service to clients and de-escalate when appropriate. Both the Administrator S1, and Assistant Administrator S2 denied the allegation. S2 stated she never set up meeting with R1. S1 denied being rude to R1. Most residents stated that staff is very kind and respectful. There is insufficient evidence to support this allegation. Allegation: Staff do not provide adequate food service to a resident. It is alleged that R1 cannot select 2 alternatives from food menu. That there is not enough food served to R1 LPA interviewed 13 residents and 12 of 13 could not collaborate the allegation. 12 of the 13 residents stated that they are only allowed 1 alternative and that it has been this way since they have been here. All Kitchen staff and Administrator stated that R1 gets double portions of everything. Staff stated they provide residents with everything he asks for. S1 stated they can increase the amount of fruit on the plate, but the fruit is seasonal and cannot be substituted always. 12 of 13 residents stated that they get enough food and can get more if they ask. Most residents stated that the food is plentiful. Some residents started the food is not very good in quality. There is insufficient evidence to support this allegation. Allegation: Resident is not being treated fairly while in care. It is alleged that residents are not being treated fairly at the facility. LPA interviewed six staff and 6 of 6 staff denied the allegations. LPA interviewed 13 residents and 12 of 13 residents stated they are treated fairly. LPA observed staff interactions during several visits and the staff treated all residents fairly and with respect and dignity. There is insufficient evidence to support this allegation. Allegation: Staff are retaliating against a resident. It is alleged that staff is retaliating against resident for complaining. LPA interviewed 6 staff and all 6 staff denied the allegations. 12 of 13 residents denied the allegation and some were surprised at the allegation. Most residents stated that they have never heard of staff retaliating against residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 28-AS-20220815140709